Provider Demographics
NPI:1720295116
Name:MIESKE, SAMUEL EDWARD (MPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EDWARD
Last Name:MIESKE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 XIMENO AVE APT 224
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-4509
Mailing Address - Country:US
Mailing Address - Phone:562-856-7640
Mailing Address - Fax:
Practice Address - Street 1:2000 E CHAPMAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4106
Practice Address - Country:US
Practice Address - Phone:714-870-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist