Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156F00000X | Technician/Technologist | CA | |
Y | 156F00000X | Technician/Technologist | 8662 | CA |
NPI | 1063098143 |
---|---|
Provider Name | Mr. Alfred Samuel |
First Address | Huntington Beach, CA 92649-3256 |
Second Address | Huntington Beach, CA 92649-3256 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2021 |
Last Update Date | 20/03/2021 |