Provider Demographics
NPI:1669725594
Name:SAMUEL, IVIE LEE
Entity type:Individual
Prefix:
First Name:IVIE
Middle Name:LEE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 W. ALEXANDER RD. UNIT 2061
Mailing Address - Street 2:
Mailing Address - City:N. LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-326-5505
Mailing Address - Fax:
Practice Address - Street 1:1881 W ALEXANDER RD UNIT 2061
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-9044
Practice Address - Country:US
Practice Address - Phone:702-326-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner