Provider Demographics
NPI:1588053805
Name:SANTOS, MARIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:SANTOS
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 1:10754 FLORALITA AVE
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-2363
Mailing Address - Country:US
Mailing Address - Phone:818-472-2933
Mailing Address - Fax:
Practice Address - Street 1:10754 FLORALITA AVE
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040-2363
Practice Address - Country:US
Practice Address - Phone:818-472-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist