Provider Demographics
NPI:1245339159
Name:FARAGALLAH, SAMIR B (DC)
Entity type:Individual
Prefix:
First Name:SAMIR
Middle Name:B
Last Name:FARAGALLAH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 CAMINO DEL RIO S STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4015
Mailing Address - Country:US
Mailing Address - Phone:619-683-2220
Mailing Address - Fax:619-441-8339
Practice Address - Street 1:3505 CAMINO DEL RIO S STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4015
Practice Address - Country:US
Practice Address - Phone:619-683-2220
Practice Address - Fax:619-677-2668
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10642111NX0800X, 111NX0800X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0106420OtherBLUE SHIELD OF CA
CADC0106420Medicaid
CA10642OtherCA STATE LC # CHIROPRACTI
CADC0106420OtherBLUE SHIELD OF CA
CADC0106420Medicaid