Provider Demographics
NPI:1205563855
Name:PORTILLO, ANDRES ARMANDO (DC)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:ARMANDO
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22158 PERALTA ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3918
Mailing Address - Country:US
Mailing Address - Phone:650-303-2889
Mailing Address - Fax:
Practice Address - Street 1:670 GREGORY LN STE C
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2771
Practice Address - Country:US
Practice Address - Phone:925-395-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor