MEDICARE: MR. ALFRED SAMUEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156F00000X	Technician/Technologist		CA
2	156F00000X	Technician/Technologist	8662	CA

General Provider Information

NPI Number	:	1063098143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALFRED SAMUEL

Provider Business Mailing Address
First Line	:	16481 WATERWAY CIR APT B
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3256
Country	:	US
Telephone Number	:	714-209-9009
Fax Number	:

Provider Business Practice Location Address
First Line	:	16481 WATERWAY CIR APT B
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3256
Country	:	US
Telephone Number	:	714-209-9009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2021
Last Update Date	:	03/20/2021

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