Provider Demographics
NPI:1770007361
Name:PORTILLO, MARIO MANUEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:MANUEL
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-316-9272
Practice Address - Street 1:20860 N TATUM BLVD STE 290
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4282
Practice Address - Country:US
Practice Address - Phone:480-563-1144
Practice Address - Fax:480-563-2371
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8652111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation