Provider Demographics
NPI:1659879021
Name:PORTALES, JOSE ENRIQUE (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ENRIQUE
Last Name:PORTALES
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4932 BOLERO CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-2545
Mailing Address - Country:US
Mailing Address - Phone:817-823-2563
Mailing Address - Fax:
Practice Address - Street 1:901 WILDCAT WAY
Practice Address - Street 2:
Practice Address - City:KENNEDALE
Practice Address - State:TX
Practice Address - Zip Code:76060-5848
Practice Address - Country:US
Practice Address - Phone:817-563-8133
Practice Address - Fax:817-563-8133
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT66422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer