Healthcare Provider Details

I. General information

NPI: 1528610896
Provider Name (Legal Business Name): LUIS SANTIAGO JR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 10/16/2026
Certification Date: 10/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 PACIFIC COAST HWY
TORRANCE CA
90505-5441
US

IV. Provider business mailing address

7515 VAN NUYS BLVD
VAN NUYS CA
91405-1949
US

V. Phone/Fax

Practice location:
  • Phone: 424-455-2273
  • Fax:
Mailing address:
  • Phone: 818-627-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number95114956
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: