Provider Demographics
NPI:1790048296
Name:ORTIZ, SAMUEL FRANCISCO
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:FRANCISCO
Last Name:ORTIZ
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 1:2310 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-1552
Mailing Address - Country:US
Mailing Address - Phone:310-569-9552
Mailing Address - Fax:
Practice Address - Street 1:1525 E 17TH ST STE B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8523
Practice Address - Country:US
Practice Address - Phone:714-542-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)