Provider Demographics
NPI:1518335066
Name:PORTILLO, KRISTINA HERRERA (DC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:HERRERA
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11075 S STATE ST STE 11B
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5190
Mailing Address - Country:US
Mailing Address - Phone:801-871-5652
Mailing Address - Fax:888-505-5245
Practice Address - Street 1:11075 S STATE ST STE 11B
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5190
Practice Address - Country:US
Practice Address - Phone:801-871-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33303111N00000X
UT9537864-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor