Healthcare Provider Details

I. General information

NPI: 1164729893
Provider Name (Legal Business Name): ELSA SANTANA MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4898 E IRLO BRONSON HWY., 2ND FLOOR ST. CLOUD FL 34744
ST. CLOUD FL
34744
US

IV. Provider business mailing address

4898 E IRLO BRONSON HWY., 2ND FLOOR ST. CLOUD FL 34744
ST. CLOUD FL
34744
US

V. Phone/Fax

Practice location:
  • Phone: 407-891-3054
  • Fax: 888-477-7678
Mailing address:
  • Phone: 407-891-3054
  • Fax: 888-477-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: