Healthcare Provider Details

I. General information

NPI: 1154011674
Provider Name (Legal Business Name): SAMUEL MARIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4284
US

IV. Provider business mailing address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4284
US

V. Phone/Fax

Practice location:
  • Phone: 310-627-4525
  • Fax:
Mailing address:
  • Phone: 310-627-4525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number1154011674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: