Healthcare Provider Details

I. General information

NPI: 1124935853
Provider Name (Legal Business Name): MIRUIDA SANTOS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FOREST PARK DR STE 4
FARMINGTON CT
06032-1428
US

IV. Provider business mailing address

4 FOREST PARK DR STE 4
FARMINGTON CT
06032-1428
US

V. Phone/Fax

Practice location:
  • Phone: 860-681-4200
  • Fax:
Mailing address:
  • Phone: 860-681-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11716
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: