Basic Information
| Provider Information | |||||||||
| NPI: | 1821157496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTUGAL | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | DIONISIO | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 WESTVIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164346886 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1550 3RD STREET | ||||||||
| Address2: | LINCOLN MANOR CARE CENTER | ||||||||
| City: | LINCOLN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166456942 | ||||||||
| FaxNumber: | 9166456942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT3279 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.