Provider Demographics
NPI:1376081950
Name:SANTOS-DAVILA, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SANTOS-DAVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 WATERSIDE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9206
Mailing Address - Country:US
Mailing Address - Phone:917-577-9098
Mailing Address - Fax:
Practice Address - Street 1:1786 WATERSIDE OAKS DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9206
Practice Address - Country:US
Practice Address - Phone:917-577-9098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
FL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123Medicaid