Provider Demographics
NPI:1255881942
Name:SANTIAGO, JOHAN DARYL
Entity type:Individual
Prefix:
First Name:JOHAN
Middle Name:DARYL
Last Name:SANTIAGO
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 1:30-4T VILLA CAROLINA
Mailing Address - Street 2:435 BLOQ 181
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983
Mailing Address - Country:US
Mailing Address - Phone:787-690-9192
Mailing Address - Fax:
Practice Address - Street 1:465 AVE DE HOSTO
Practice Address - Street 2:URB EL VEDADO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-946-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1923133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist