Healthcare Provider Details

I. General information

NPI: 1376892190
Provider Name (Legal Business Name): BERTA ALICIA PORTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BERTA ALICIA PORTILLO ACOSTA

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 HILLTOP
SOCORRO NM
87801
US

IV. Provider business mailing address

313 HILLTOP ST
SOCORRO NM
87801-4123
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-8361
  • Fax:
Mailing address:
  • Phone: 505-433-8361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7410
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: