Provider Demographics
NPI:1215567888
Name:REYES, ERNEST LYSANDER SANTIAGO (PTA)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:LYSANDER SANTIAGO
Last Name:REYES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 IVY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1243
Mailing Address - Country:US
Mailing Address - Phone:818-531-6986
Mailing Address - Fax:
Practice Address - Street 1:837 S FAIR OAKS AVE STE 204
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2647
Practice Address - Country:US
Practice Address - Phone:626-627-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50483225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant