Healthcare Provider Details

I. General information

NPI: 1760514475
Provider Name (Legal Business Name): GLENDA LAUREN SANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 S MARYLAND PKWY STE 108
LAS VEGAS NV
89109-1564
US

IV. Provider business mailing address

7410 S BROADWAY
LOS ANGELES CA
90003-2034
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-7779
  • Fax: 702-778-4226
Mailing address:
  • Phone: 323-541-9016
  • Fax: 323-541-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: