Provider Demographics
NPI:1144793258
Name:SAMUELS, KENNETH
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:SAMUELS
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 1:938 WILD FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3209
Mailing Address - Country:US
Mailing Address - Phone:754-209-5415
Mailing Address - Fax:
Practice Address - Street 1:938 WILD FOREST DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3209
Practice Address - Country:US
Practice Address - Phone:844-381-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD37473747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant