Provider Demographics
NPI:1710547583
Name:SANTOS, JIOVANNI CARLOS
Entity Type:Individual
Prefix:
First Name:JIOVANNI
Middle Name:CARLOS
Last Name:SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 FLORIDA ST UNIT C121
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6226
Mailing Address - Country:US
Mailing Address - Phone:619-453-1885
Mailing Address - Fax:
Practice Address - Street 1:1315 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2107
Practice Address - Country:US
Practice Address - Phone:719-961-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility