Provider Demographics
NPI:1700412459
Name:PORTILLO, MARCO A JR
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:A
Last Name:PORTILLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W KIMBERLY AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6346
Mailing Address - Country:US
Mailing Address - Phone:714-203-6595
Mailing Address - Fax:
Practice Address - Street 1:701 W KIMBERLY AVE STE 125
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6346
Practice Address - Country:US
Practice Address - Phone:714-203-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician