Provider Demographics
NPI:1972839124
Name:SAMUEL, HAZEL (OWNER)
Entity Type:Individual
Prefix:MRS
First Name:HAZEL
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 BOSUNS WAY
Mailing Address - Street 2:A4
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6708
Mailing Address - Country:US
Mailing Address - Phone:734-829-8627
Mailing Address - Fax:
Practice Address - Street 1:5050 BOSUNS WAY
Practice Address - Street 2:A4
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-6708
Practice Address - Country:US
Practice Address - Phone:734-829-8627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI383716007374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide