Provider Demographics
NPI:1518540947
Name:PACHECO, SAMANTHA ALYSSA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ALYSSA
Last Name:PACHECO
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 1:16360 ROSCOE BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1219
Mailing Address - Country:US
Mailing Address - Phone:818-901-4830
Mailing Address - Fax:818-901-8985
Practice Address - Street 1:6305 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2346
Practice Address - Country:US
Practice Address - Phone:818-908-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner