Provider Demographics
NPI:1063098143
Name:SAMUEL, ALFRED
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16481 WATERWAY CIR APT B
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3256
Mailing Address - Country:US
Mailing Address - Phone:714-209-9009
Mailing Address - Fax:
Practice Address - Street 1:16481 WATERWAY CIR APT B
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3256
Practice Address - Country:US
Practice Address - Phone:714-209-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156F00000X
CA8662156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist