1073990495 NPI number — ORTHOPEDIC AND SPORTS MEDICINE CENTER

Table of content: (NPI 1073990495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073990495 NPI number — ORTHOPEDIC AND SPORTS MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC AND SPORTS MEDICINE CENTER
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:
1073990495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 513228
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:
90051-3228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-456-3908
Provider Business Mailing Address Fax Number:
714-456-2338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 NEWPORT BLVD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92627-3786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-515-5210
Provider Business Practice Location Address Fax Number:
855-519-4485
Provider Enumeration Date:
05/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PORTO
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM PRESIDENT
Authorized Official Telephone Number:
714-456-2986

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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