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NPI Code Detail

MEDICARE: SAMUEL ELIJAH THIBODEAUX

MEDICARE: SAMUEL ELIJAH THIBODEAUX
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
1101YA0400XAddiction (Substance Use Disorder) Counselor008210973LA

General Provider Information

NPI Number : 1548008162
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMUEL ELIJAH THIBODEAUX
Provider Business Mailing Address
First Line : 16662 IRBY LN
Second Line :
City : HUNTINGTON BEACH
State : CA
Zip : 92647-4919
Country : US
Telephone Number : 737-318-5140
Fax Number :
Provider Business Practice Location Address
First Line : 601 S HARBOR BLVD
Second Line :
City : ANAHEIM
State : CA
Zip : 92805-4521
Country : US
Telephone Number : 714-908-0028
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2024
Last Update Date : 07/24/2024

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Directions to “ SAMUEL ELIJAH THIBODEAUX ” Practice Location

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