Healthcare Provider Details

I. General information

NPI: 1558183061
Provider Name (Legal Business Name): SAMUEL JAMES BLEES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4347 UTAH ST
SAN DIEGO CA
92104-1212
US

IV. Provider business mailing address

34800 BOB WILSON DRIVE
APO AA
92134
US

V. Phone/Fax

Practice location:
  • Phone: 651-249-7264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: