=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649483249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO PEDITRICO DR SANTIAGO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35-25 CALLE 16 VILLA CAROLINA
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00985-5440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-701-0669
-----------------------------------------------------
Fax | 787-701-0611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 37321
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00937-0321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-701-0669
-----------------------------------------------------
Fax | 787-701-0611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARISEL SANTIAGO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-701-0669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 10609
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------