Healthcare Provider Details

I. General information

NPI: 1659059046
Provider Name (Legal Business Name): MR. SAMUEL J GRIFFIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9526 RALEIGH DR
EL PASO TX
79924-6208
US

IV. Provider business mailing address

9526 RALEIGH DR
EL PASO TX
79924-6208
US

V. Phone/Fax

Practice location:
  • Phone: 915-850-3868
  • Fax:
Mailing address:
  • Phone: 915-850-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: