Provider Demographics
NPI:1366767451
Name:PORATH CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:PORATH CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:PORATH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-313-4212
Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:1748 W KATELLA AVE
Practice Address - Street 2:107
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-3437
Practice Address - Country:US
Practice Address - Phone:714-313-4212
Practice Address - Fax:714-464-5365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26124111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26124OtherD.C. LICENSE
CAINDIVIDUAL NPIOther1659696748
CAZZZ03106ZOtherBLUE SHIELD