Healthcare Provider Details

I. General information

NPI: 1295655330
Provider Name (Legal Business Name): DAVID LEE SAMUELS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ARCADIA RD APT A
HACKENSACK NJ
07601-1249
US

IV. Provider business mailing address

210 STUYVESANT AVE
NEWARK NJ
07106-7000
US

V. Phone/Fax

Practice location:
  • Phone: 551-332-0646
  • Fax:
Mailing address:
  • Phone: 551-332-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT01589600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: