Basic Information
Provider Information
NPI: 1477101517
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SAMSON
FirstName: IDALIAS
MiddleName: MELIA
NamePrefix:  
NameSuffix:  
Credential: RBT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 12134 OZARK PL
Address2:  
City: PEYTON
State: CO
PostalCode: 808313000
CountryCode: US
TelephoneNumber: 7197614189
FaxNumber:  
Practice Location
Address1: 5526 N ACADEMY BLVD STE 109
Address2:  
City: COLORADO SPRINGS
State: CO
PostalCode: 809183688
CountryCode: US
TelephoneNumber: 7193015100
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/02/2019
LastUpdateDate: 09/02/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X COY    

No ID Information.


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