Provider Demographics
NPI:1942573597
Name:PORTILLO, NANCY (DC)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
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 1:3755 E MAIN ST
Mailing Address - Street 2:SUITE 158
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2463
Mailing Address - Country:US
Mailing Address - Phone:630-377-3344
Mailing Address - Fax:
Practice Address - Street 1:3755 E MAIN ST
Practice Address - Street 2:SUITE 158
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2463
Practice Address - Country:US
Practice Address - Phone:630-377-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor