Healthcare Provider Details

I. General information

NPI: 1750155867
Provider Name (Legal Business Name): ABRAHAM SANTIAGO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 RIVERWALK PKWY STE 114
RIVERSIDE CA
92505-3374
US

IV. Provider business mailing address

3191 MISSION INN AVE STE B
RIVERSIDE CA
92507-4188
US

V. Phone/Fax

Practice location:
  • Phone: 951-324-4291
  • Fax: 951-684-2980
Mailing address:
  • Phone: 951-684-2874
  • Fax: 951-684-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number305091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: