Provider Demographics
NPI:1194194860
Name:SAMUEL T. ENTERPRISE
Entity type:Organization
Organization Name:SAMUEL T. ENTERPRISE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:TESORO
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:714-847-7585
Mailing Address - Street 1:3151 AIRWAY AVE
Mailing Address - Street 2:SUITE D2
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4607
Mailing Address - Country:US
Mailing Address - Phone:714-847-7585
Mailing Address - Fax:714-848-5410
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:SUITE D2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-847-7585
Practice Address - Fax:714-848-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherFREE STANDING FACILITY