Provider Demographics
NPI:1366613770
Name:SAMRA UNIVERSITY
Entity type:Organization
Organization Name:SAMRA UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM LAC
Authorized Official - Phone:213-381-1700
Mailing Address - Street 1:1730 W OLYMPIC BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1019
Mailing Address - Country:US
Mailing Address - Phone:213-381-1700
Mailing Address - Fax:213-381-1701
Practice Address - Street 1:1730 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1019
Practice Address - Country:US
Practice Address - Phone:213-381-1700
Practice Address - Fax:213-381-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health