Provider Demographics
NPI:1932749157
Name:PORTILLO, MANOLITO JOSE II
Entity type:Individual
Prefix:MR
First Name:MANOLITO
Middle Name:JOSE
Last Name:PORTILLO
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:CO PREVENTION AND RECOVERY
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-0908
Mailing Address - Country:US
Mailing Address - Phone:580-492-3614
Mailing Address - Fax:
Practice Address - Street 1:8501 NW MADISCHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1221
Practice Address - Country:US
Practice Address - Phone:580-492-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist