1144347964 NPI number — DR. KI YOUNG LEE PORTILLO AU.D.

Table of content: DR. KI YOUNG LEE PORTILLO AU.D. (NPI 1144347964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144347964 NPI number — DR. KI YOUNG LEE PORTILLO AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTILLO
Provider First Name:
KI YOUNG
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE-PORTILLO
Provider Other First Name:
KI YOUNG
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144347964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90031-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-442-5790
Provider Business Mailing Address Fax Number:
323-442-5740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 SAN PABLO ST STE 5100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-5310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-442-5790
Provider Business Practice Location Address Fax Number:
323-442-5740
Provider Enumeration Date:
03/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AU 1759 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)