1366767451 NPI number — PORATH CHIROPRACTIC CORPORATION

Table of content: (NPI 1366767451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366767451 NPI number — PORATH CHIROPRACTIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORATH CHIROPRACTIC CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366767451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15550 ROCKFIELD BLVD
Provider Second Line Business Mailing Address:
B220
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-598-9999
Provider Business Mailing Address Fax Number:
949-598-9990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1748 W KATELLA AVE
Provider Second Line Business Practice Location Address:
107
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92867-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-313-4212
Provider Business Practice Location Address Fax Number:
714-464-5365
Provider Enumeration Date:
03/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PORATH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER / PROVIDER
Authorized Official Telephone Number:
714-313-4212

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC26124 , 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)

  • Identifier: DC26124 . This is a "D.C. LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: INDIVIDUAL NPI . This is a "1659696748" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ03106Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".