Healthcare Provider Details

I. General information

NPI: 1164607966
Provider Name (Legal Business Name): ELDA L. SANTIAGO PEREZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 670 KAROMA PLAZA SUITE #12
MANATI PR
00674
US

IV. Provider business mailing address

PO BOX 2191
MANATI PR
00674-2191
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-1546
  • Fax: 787-633-1575
Mailing address:
  • Phone: 787-854-1546
  • Fax: 787-633-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number367
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier84143SA
Identifier TypeMEDICAID
Identifier StatePR
Identifier Issuer

VIII. Authorized Official

Name: ELDA L SANTIAGO-PEREZ
Title or Position: ADMINISTRATOR
Credential: RPT
Phone: 787-854-1546