Provider Demographics
NPI:1457718827
Name:DE SANTIAGO, CARLOS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:DE 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 1:1230 MENLO AVE
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3593
Mailing Address - Country:US
Mailing Address - Phone:213-365-7400
Mailing Address - Fax:213-201-1812
Practice Address - Street 1:1230 MENLO AVE
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3593
Practice Address - Country:US
Practice Address - Phone:213-365-7400
Practice Address - Fax:213-201-1812
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner