MEDICARE: MR. MAURICE BRADLEY SAMPSON III CTRC

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	171400000X	Health & Wellness Coach		CA

General Provider Information

NPI Number	:	1487328845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAURICE BRADLEY SAMPSON III CTRC

Provider Business Mailing Address
First Line	:	5006 COOLIDGE AVE
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-5176
Country	:	US
Telephone Number	:	831-359-5894
Fax Number	:

Provider Business Practice Location Address
First Line	:	5006 COOLIDGE AVE
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-5176
Country	:	US
Telephone Number	:	831-359-5894
Fax Number	:

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

Provider Enumeration Date	:	08/08/2021
Last Update Date	:	08/08/2021

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