Provider Demographics
NPI:1700103223
Name:PORTOLA ANESTHESIA SERVICES LLC
Entity type:Organization
Organization Name:PORTOLA ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-837-3338
Mailing Address - Street 1:29300 PORTOLA PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8718
Mailing Address - Country:US
Mailing Address - Phone:949-837-3338
Mailing Address - Fax:949-716-2725
Practice Address - Street 1:29300 PORTOLA PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8718
Practice Address - Country:US
Practice Address - Phone:949-837-3338
Practice Address - Fax:949-716-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty