Provider Demographics
NPI:1770053878
Name:PORTILLO DE LA CRUZ, EDNA CATALINA (RD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:CATALINA
Last Name:PORTILLO DE LA CRUZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:CATALINA
Other - Last Name:PORTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:801 W VALLEY BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3257
Mailing Address - Country:US
Mailing Address - Phone:626-283-5128
Mailing Address - Fax:
Practice Address - Street 1:801 W VALLEY BLVD STE 206
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3257
Practice Address - Country:US
Practice Address - Phone:626-283-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1024132133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered