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General NPI Number Information
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NPI Number | 1215567888
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Entity Type | Individual
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Provider Name | ERNEST LYSANDER SANTIAGO REYES PTA
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Gender | Male
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Dates
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Enumeration Date | 01/22/2020
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Last Update Date | 01/22/2020
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Provider Practice Location Address
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Address Line | 837 S FAIR OAKS AVE STE 204
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City | PASADENA
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State | CA
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Zip | 91105-2647
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Country | US
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Telephone | 626-627-2141
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Fax |
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Provider Business Mailing Address
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Address Line | 500 IVY ST STE 200
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City | GLENDALE
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State | CA
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Zip | 91204-1243
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Country | US
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Telephone | 818-531-6986
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 50483
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License Number State | CA
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