Provider Demographics
NPI:1235811290
Name:SAMRA ENTERPRISE, LLC
Entity type:Organization
Organization Name:SAMRA ENTERPRISE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-900-5850
Mailing Address - Street 1:PO BOX 1752
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-1752
Mailing Address - Country:US
Mailing Address - Phone:760-900-5850
Mailing Address - Fax:760-628-2249
Practice Address - Street 1:14644 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-7003
Practice Address - Country:US
Practice Address - Phone:760-323-3355
Practice Address - Fax:760-437-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-01
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty