Provider Demographics
NPI:1336569284
Name:PORTILLO, AMERICA
Entity Type:Individual
Prefix:
First Name:AMERICA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 W STEVENS AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-5033
Mailing Address - Country:US
Mailing Address - Phone:714-914-0515
Mailing Address - Fax:
Practice Address - Street 1:7281 GARDEN GROVE BLVD STE H
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4212
Practice Address - Country:US
Practice Address - Phone:714-914-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90397735F13358OtherBENEFITS IDENTIFICATION CARD