Provider Demographics
NPI:1679286884
Name:SANTOS, GUSTAVO RENE
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:RENE
Last Name:SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-0096
Mailing Address - Country:US
Mailing Address - Phone:787-354-0318
Mailing Address - Fax:
Practice Address - Street 1:URB ALTOS DE LA FUENTE
Practice Address - Street 2:CALLE 8 D45
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-354-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR886111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor