Provider Demographics
NPI:1083315733
Name:AUGUSTIN, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:AUGUSTIN
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 1:25261 LA MAR RD APT D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3023
Mailing Address - Country:US
Mailing Address - Phone:323-803-9864
Mailing Address - Fax:323-803-9864
Practice Address - Street 1:1151 DOVE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2840
Practice Address - Country:US
Practice Address - Phone:949-630-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician