Provider Demographics
NPI:1336869569
Name:PEREZ CUSTODIO, SANTOS (DC)
Entity Type:Individual
Prefix:
First Name:SANTOS
Middle Name:
Last Name:PEREZ CUSTODIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 FERNANDA DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-7120
Mailing Address - Country:US
Mailing Address - Phone:787-669-7786
Mailing Address - Fax:
Practice Address - Street 1:70 FOX RIDGE CT
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2752
Practice Address - Country:US
Practice Address - Phone:386-668-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor