Healthcare Provider Details

I. General information

NPI: 1851076426
Provider Name (Legal Business Name): SAMADRA EMBRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 W MANCHESTER AVE STE 206F
LOS ANGELES CA
90047-3057
US

IV. Provider business mailing address

4228 W 129TH ST APT B
HAWTHORNE CA
90250-5559
US

V. Phone/Fax

Practice location:
  • Phone: 424-444-8538
  • Fax:
Mailing address:
  • Phone: 424-444-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: