Healthcare Provider Details

I. General information

NPI: 1083376446
Provider Name (Legal Business Name): GREGORY SANTIAGO LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 E AZTEC AVE STE B
GALLUP NM
87301-5085
US

IV. Provider business mailing address

10900 TANZANITE DR NW
ALBUQUERQUE NM
87114-1853
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-9644
  • Fax: 505-896-2958
Mailing address:
  • Phone: 505-239-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT9112
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: