Provider Demographics
NPI:1942577341
Name:SAMUELS, ROY OLIVER
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:OLIVER
Last Name:SAMUELS
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 1:1385 TRAVERS CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3581
Mailing Address - Country:US
Mailing Address - Phone:718-807-7058
Mailing Address - Fax:
Practice Address - Street 1:1385 TRAVERS CREEK TRL
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3581
Practice Address - Country:US
Practice Address - Phone:718-807-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057718186347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle