=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568706992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUELS VALLEY PROFESSIONAL SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2012
-----------------------------------------------------
Last Update Date | 11/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 PALMVIEW DR STE A
-----------------------------------------------------
City | PALMVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-8176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-283-0566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1449 W DURANTA AVE STE 3
-----------------------------------------------------
City | ALAMO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78516-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-283-0566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARTEL SAMUELS
-----------------------------------------------------
Credential | M.D,
-----------------------------------------------------
Telephone | 361-673-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------