MEDICARE: DORA DE SANTIAGO ADULT FOSTER CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility		TX

General Provider Information

NPI Number	:	1114144854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DORA DE SANTIAGO ADULT FOSTER CARE

Provider Business Mailing Address
First Line	:	211 ZACHRY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-4157
Country	:	US
Telephone Number	:	210-434-5257
Fax Number	:	210-434-5257

Provider Business Practice Location Address
First Line	:	211 ZACHRY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-4157
Country	:	US
Telephone Number	:	210-434-5257
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DORA DE SANTIAGO
Credential	:
Telephone Number	:	210-434-5257

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	09/25/2008

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