Healthcare Provider Details

I. General information

NPI: 1669303970
Provider Name (Legal Business Name): VICTOR ANGEL SANTILLANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

756 LALTON DR
CONWAY SC
29526-7890
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-8104
  • Fax:
Mailing address:
  • Phone: 843-234-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: