Healthcare Provider Details

I. General information

NPI: 1689510349
Provider Name (Legal Business Name): BIANCA PORTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17701 AVALON BLVD SPC 410
CARSON CA
90746-7195
US

IV. Provider business mailing address

17701 AVALON BLVD SPC 410
CARSON CA
90746-7195
US

V. Phone/Fax

Practice location:
  • Phone: 424-298-5420
  • Fax:
Mailing address:
  • Phone: 424-298-5420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: