Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1864 | SC |
NPI | 1255646196 |
---|---|
Provider Name | Dr. Lad Santiago |
First Address | Fairforest, SC 29336-0825 |
Second Address | Spartanburg, SC 29301-5671 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2010 |
Last Update Date | 16/08/2010 |