Provider Demographics
NPI:1871962076
Name:PORTOLA MEDICAL SERVICES PC
Entity type:Organization
Organization Name:PORTOLA MEDICAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-813-9728
Mailing Address - Street 1:29100 PORTOLA PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8712
Mailing Address - Country:US
Mailing Address - Phone:844-254-6382
Mailing Address - Fax:331-442-4902
Practice Address - Street 1:29100 PORTOLA PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8712
Practice Address - Country:US
Practice Address - Phone:844-254-6382
Practice Address - Fax:331-442-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty