Basic Information
| Provider Information | |||||||||
| NPI: | 1457984973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | JOHALYS | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140053 | ||||||||
| Address2: | |||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006140053 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | LAS VEGAS MALL LOCAL DD-2 | ||||||||
| Address2: | |||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879153000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2020 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2222-2 | PR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 6746664 | 01 | PR | DRIVERS LICENSE | OTHER |