MEDICARE: MARLENE Y SAMUELS MED-WAIVER PROVIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174037592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE Y SAMUELS MED-WAIVER PROVIDER

Provider Business Mailing Address
First Line	:	4241 SW HAGAPLAN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6583
Country	:	US
Telephone Number	:	772-224-4466
Fax Number	:

Provider Business Practice Location Address
First Line	:	4241 SW HAGAPLAN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6583
Country	:	US
Telephone Number	:	772-224-4466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2017
Last Update Date	:	11/21/2017

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