Provider Demographics
NPI:1265821672
Name:SAMUELS, KHALEED (DC CCSP)
Entity Type:Individual
Prefix:DR
First Name:KHALEED
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:DC CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 S WESTERN AVE UNIT 227
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-1204
Mailing Address - Country:US
Mailing Address - Phone:310-684-1807
Mailing Address - Fax:310-684-1607
Practice Address - Street 1:1423 W 8TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3803
Practice Address - Country:US
Practice Address - Phone:310-684-1807
Practice Address - Fax:310-684-1607
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33008111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47-2728752OtherEIN