1871095687 NPI number — MS. MARTINA JENKINS PORTILLO R.N, MPH

Table of content: MS. MARTINA JENKINS PORTILLO R.N, MPH (NPI 1871095687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871095687 NPI number — MS. MARTINA JENKINS PORTILLO R.N, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTILLO
Provider First Name:
MARTINA
Provider Middle Name:
JENKINS
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.N, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALLAGHAN
Provider Other First Name:
MARTINA
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871095687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAUMA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92061-0406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-749-1410
Provider Business Mailing Address Fax Number:
760-749-4122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50100 GOLSH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY CENTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92082-5338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-749-1410
Provider Business Practice Location Address Fax Number:
760-749-4122
Provider Enumeration Date:
03/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WC1500X , with the licence number:  219534 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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