Provider Demographics
NPI:1164192456
Name:PARRA ROMERO, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PARRA ROMERO
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 1:1300 W FLORIDA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4628
Mailing Address - Country:US
Mailing Address - Phone:951-658-7122
Mailing Address - Fax:951-658-7140
Practice Address - Street 1:1300 W FLORIDA AVE STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4628
Practice Address - Country:US
Practice Address - Phone:951-658-7122
Practice Address - Fax:951-658-7140
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 172V00000X
CAF5206142172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker