Provider Demographics
NPI:1619799277
Name:SANTIAGO, GABRIEL EMMANUEL
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:EMMANUEL
Last Name:SANTIAGO
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 1:747 W TORINO PL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122
Mailing Address - Country:US
Mailing Address - Phone:520-450-6743
Mailing Address - Fax:
Practice Address - Street 1:312 W 10TH ST STE 2
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-3940
Practice Address - Country:US
Practice Address - Phone:520-222-7385
Practice Address - Fax:866-727-9116
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty