Provider Demographics
NPI:1841419645
Name:SANTORE, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:SANTORE
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 1:6551 MANTOVA DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVENUE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-427-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist