Provider Demographics
NPI:1508571001
Name:SAMON RODRIGUEZ, MIRTA MARINA
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:MARINA
Last Name:SAMON RODRIGUEZ
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 1:2829 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3304
Mailing Address - Country:US
Mailing Address - Phone:213-699-7000
Mailing Address - Fax:
Practice Address - Street 1:2829 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3304
Practice Address - Country:US
Practice Address - Phone:213-699-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA704995164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse