Healthcare Provider Details

I. General information

NPI: 1679469969
Provider Name (Legal Business Name): JOSE JERRY SANTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2025
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28632 ROADSIDE DR STE 170
AGOURA HILLS CA
91301-6083
US

IV. Provider business mailing address

28632 ROADSIDE DR STE 170
AGOURA HILLS CA
91301-6083
US

V. Phone/Fax

Practice location:
  • Phone: 888-561-0868
  • Fax:
Mailing address:
  • Phone: 888-561-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: