Provider Demographics
NPI:1346959509
Name:PORTILLO, ANTHONY (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 N ALDENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1522
Mailing Address - Country:US
Mailing Address - Phone:626-315-3789
Mailing Address - Fax:
Practice Address - Street 1:100 N BARRANCA ST STE 920
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1654
Practice Address - Country:US
Practice Address - Phone:626-263-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist