Provider Demographics
NPI:1083991889
Name:SAMSON, MARCIANA MENDOZA
Entity Type:Individual
Prefix:
First Name:MARCIANA
Middle Name:MENDOZA
Last Name:SAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8106 TILDEN AVE
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5243
Mailing Address - Country:US
Mailing Address - Phone:818-464-6551
Mailing Address - Fax:
Practice Address - Street 1:8106 TILDEN AVE
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5243
Practice Address - Country:US
Practice Address - Phone:818-464-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5434171172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver