Provider Demographics
NPI:1669814448
Name:HUMPHRIES, SAMANTHA JANE (LAC)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:JANE
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8692 9TH ST UNIT 14
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0806
Mailing Address - Country:US
Mailing Address - Phone:909-518-3126
Mailing Address - Fax:
Practice Address - Street 1:114 N INDIAN HILL BLVD STE G
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4642
Practice Address - Country:US
Practice Address - Phone:909-518-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15179171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist