1649634239 NPI number — JEFFREY WILLIAM WYLIE SAMUELSON CPHT

Table of content: JEFFREY WILLIAM WYLIE SAMUELSON CPHT (NPI 1649634239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649634239 NPI number — JEFFREY WILLIAM WYLIE SAMUELSON CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMUELSON
Provider First Name:
JEFFREY
Provider Middle Name:
WILLIAM WYLIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPHT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMUELSON
Provider Other First Name:
JEFFREY
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPHT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1649634239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1423 BROADWAY STE 122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94612-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-984-4916
Provider Business Mailing Address Fax Number:
510-989-9089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2175 MARKET STREET
Provider Second Line Business Practice Location Address:
UNIT 122
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94114-1477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
628-895-9508
Provider Business Practice Location Address Fax Number:
628-895-9509
Provider Enumeration Date:
04/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183700000X , with the licence number:  134195 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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