Healthcare Provider Details

I. General information

NPI: 1790606515
Provider Name (Legal Business Name): RAYSHAWN SAMPLE MLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RAY SAMPLE MLS

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1745
SEAFORD DE
19973-6145
US

IV. Provider business mailing address

PO BOX 1745
SEAFORD DE
19973-6145
US

V. Phone/Fax

Practice location:
  • Phone: 302-569-2625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: