Provider Demographics
NPI:1306996731
Name:PORTILLO, ROBERT A (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 SIXES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7856
Mailing Address - Country:US
Mailing Address - Phone:770-704-4580
Mailing Address - Fax:770-704-9142
Practice Address - Street 1:3755 SIXES RD STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-7856
Practice Address - Country:US
Practice Address - Phone:770-704-4580
Practice Address - Fax:770-704-9142
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007986111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician