Provider Demographics
NPI:1972135192
Name:CHAVEZ, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4283 EL CAJON BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1289
Mailing Address - Country:US
Mailing Address - Phone:619-521-1743
Mailing Address - Fax:
Practice Address - Street 1:4283 EL CAJON BLVD STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1289
Practice Address - Country:US
Practice Address - Phone:619-521-1743
Practice Address - Fax:619-393-0242
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD1353805OtherDRIVER LICENSE