Provider Demographics
NPI:1558908384
Name:SANTOS, STACEY SUGATAN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:SUGATAN
Last Name:SANTOS
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 1:19000 HAWTHORNE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1517
Mailing Address - Country:US
Mailing Address - Phone:310-793-1800
Mailing Address - Fax:
Practice Address - Street 1:19000 HAWTHORNE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1517
Practice Address - Country:US
Practice Address - Phone:310-793-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA50104208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation