Provider Demographics
NPI:1942911219
Name:CAPISTRANO, ROBERTO SANTOS (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:SANTOS
Last Name:CAPISTRANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 GREYCLOUD LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4219
Mailing Address - Country:US
Mailing Address - Phone:909-964-9265
Mailing Address - Fax:
Practice Address - Street 1:1046 GREYCLOUD LN
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4219
Practice Address - Country:US
Practice Address - Phone:909-964-9265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty