Provider Demographics
NPI:1548731805
Name:SANTOS, JEREMY C (PTA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:C
Last Name:SANTOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 MONTERA ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1807
Mailing Address - Country:US
Mailing Address - Phone:619-948-1371
Mailing Address - Fax:
Practice Address - Street 1:220 E 24TH ST
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-6705
Practice Address - Country:US
Practice Address - Phone:619-474-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA49596225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant