Provider Demographics
NPI:1881209880
Name:PORTILLO, VICTOR
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:PORTILLO
Suffix:
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 1:21724 ROAD 30
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-8005
Mailing Address - Country:US
Mailing Address - Phone:209-631-8435
Mailing Address - Fax:
Practice Address - Street 1:21724 ROAD 30
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8005
Practice Address - Country:US
Practice Address - Phone:209-631-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)