Healthcare Provider Details

I. General information

NPI: 1639785876
Provider Name (Legal Business Name): CARLOS E SANTOS JR. FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLIE SANTOS FNP-BC

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31700 TEMECULA PKWY
TEMECULA CA
92592-5896
US

IV. Provider business mailing address

6033 E PRADO ST
ANAHEIM CA
92807-3938
US

V. Phone/Fax

Practice location:
  • Phone: 951-331-2200
  • Fax:
Mailing address:
  • Phone: 909-762-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020008511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: