Healthcare Provider Details

I. General information

NPI: 1164789541
Provider Name (Legal Business Name): ROBERT S SANTANA RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 LOS FELIZ BLVD APT 7
LOS ANGELES CA
90027-2374
US

IV. Provider business mailing address

3705 S LA BREA AVE
LOS ANGELES CA
90016-5309
US

V. Phone/Fax

Practice location:
  • Phone: 708-334-0220
  • Fax:
Mailing address:
  • Phone: 323-293-4488
  • Fax: 323-293-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: