Provider Demographics
NPI:1598191868
Name:SANTOS, GENEROSA
Entity Type:Individual
Prefix:
First Name:GENEROSA
Middle Name:
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 1:1430 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-5056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-5056
Practice Address - Country:US
Practice Address - Phone:727-443-6010
Practice Address - Fax:727-443-6010
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8472171W00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013592400Medicaid
FL687635896Medicaid