1659879021 NPI number — MR. JOSE ENRIQUE PORTALES ATC, LAT

Table of content: MR. JOSE ENRIQUE PORTALES ATC, LAT (NPI 1659879021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659879021 NPI number — MR. JOSE ENRIQUE PORTALES ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTALES
Provider First Name:
JOSE
Provider Middle Name:
ENRIQUE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659879021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4932 BOLERO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76135-2545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-823-2563
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 WILDCAT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76060-5848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-563-8133
Provider Business Practice Location Address Fax Number:
817-563-8133
Provider Enumeration Date:
01/31/2018

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: 2255A2300X , with the licence number:  AT6642 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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