Provider Demographics
NPI:1427558287
Name:MBAIRE, SAMUEL M
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:MBAIRE
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 1:8839 TUCKER ST
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2233
Mailing Address - Country:US
Mailing Address - Phone:214-414-5793
Mailing Address - Fax:
Practice Address - Street 1:8839 TUCKER ST
Practice Address - Street 2:
Practice Address - City:CROSSROADS
Practice Address - State:TX
Practice Address - Zip Code:76227-2233
Practice Address - Country:US
Practice Address - Phone:214-414-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300596164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse