Healthcare Provider Details

I. General information

NPI: 1053248898
Provider Name (Legal Business Name): DR. JUAN PORTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 927
LAS VEGAS NM
87701-0927
US

IV. Provider business mailing address

PO BOX 927
LAS VEGAS NM
87701-0927
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-8118
  • Fax:
Mailing address:
  • Phone: 505-459-8118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11944
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number436493
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number436551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: