=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285963769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD A PORTILLO O D A PROFESSIONAL OPTOMETRIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2009
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 I ST
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95354-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-578-4885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1743
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95353-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-578-4885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD ALAN PORTILLO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 209-578-4885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 7865T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------