1083376446 NPI number — GREGORY SANTIAGO LMT

Table of content: GREGORY SANTIAGO LMT (NPI 1083376446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083376446 NPI number — GREGORY SANTIAGO LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANTIAGO
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083376446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10900 TANZANITE DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-239-9644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1206 E AZTEC AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-5085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-239-9644
Provider Business Practice Location Address Fax Number:
505-896-2958
Provider Enumeration Date:
10/12/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT9112 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 273506899 . This is a "VA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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