Provider Demographics
NPI:1366969693
Name:SANTIAGO, IRIS J
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:J
Last Name:SANTIAGO
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 1:78 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2017
Mailing Address - Country:US
Mailing Address - Phone:978-758-4994
Mailing Address - Fax:978-669-8003
Practice Address - Street 1:78 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2017
Practice Address - Country:US
Practice Address - Phone:978-758-4994
Practice Address - Fax:978-669-8003
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS37399817172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver