Provider Demographics
NPI:1134464928
Name:ESTOR, SANTOS W (COTA)
Entity Type:Individual
Prefix:
First Name:SANTOS
Middle Name:W
Last Name:ESTOR
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CALIFORNIA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:965 N BRIGHTON CIR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-2036
Practice Address - Country:US
Practice Address - Phone:815-893-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002250A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility