Healthcare Provider Details

I. General information

NPI: 1295662609
Provider Name (Legal Business Name): MARIO SANTOS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6018 SW 18TH ST STE C11
BOCA RATON FL
33433-7166
US

IV. Provider business mailing address

6018 SW 18TH ST STE C11
BOCA RATON FL
33433-7166
US

V. Phone/Fax

Practice location:
  • Phone: 561-564-0646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT36607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: