Healthcare Provider Details

I. General information

NPI: 1881240125
Provider Name (Legal Business Name): JOLUIS DE LOS SANTOS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRIDGE ST STE 71
IRVINGTON NY
10533-1560
US

IV. Provider business mailing address

1035 AVIATION BLVD
HERMOSA BEACH CA
90254-4023
US

V. Phone/Fax

Practice location:
  • Phone: 914-478-0608
  • Fax:
Mailing address:
  • Phone: 310-937-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number297795
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number044481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: