Provider Demographics
NPI:1639835309
Name:SANTILLANES, SIMON C (PTA)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:C
Last Name:SANTILLANES
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 1:5220 SPRING VALLEY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2512
Mailing Address - Country:US
Mailing Address - Phone:214-466-1340
Mailing Address - Fax:214-466-1378
Practice Address - Street 1:930 W CENTERVILLE RD STE 930
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5823
Practice Address - Country:US
Practice Address - Phone:972-303-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2166665225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant