Healthcare Provider Details

I. General information

NPI: 1770007361
Provider Name (Legal Business Name): MARIO MANUEL PORTILLO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20860 N TATUM BLVD STE 290
PHOENIX AZ
85050-4282
US

IV. Provider business mailing address

1839 S ALMA SCHOOL RD STE 354
MESA AZ
85210-3028
US

V. Phone/Fax

Practice location:
  • Phone: 480-563-1144
  • Fax: 480-563-2371
Mailing address:
  • Phone: 480-726-2287
  • Fax: 888-316-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8652
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number8652
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: