MEDICARE: DR. JUAN PORTLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C-11944	NM
2	225100000X	Physical Therapist	436493	NM
3	225X00000X	Occupational Therapist	436551	NM

General Provider Information

NPI Number	:	1053248898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN PORTLEY

Provider Business Mailing Address
First Line	:	PO BOX 927
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-0927
Country	:	US
Telephone Number	:	505-459-8118
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 927
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-0927
Country	:	US
Telephone Number	:	505-459-8118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2026
Last Update Date	:	05/06/2026

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Directions to “ DR. JUAN PORTLEY ” Practice Location

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