Provider Demographics
NPI:1164192456
Name:PARRA ROMERO, SAMUEL SANTIAGO (TPP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SANTIAGO
Last Name:PARRA ROMERO
Suffix:
Gender:M
Credentials:TPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W FLORIDA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4628
Mailing Address - Country:US
Mailing Address - Phone:951-658-7122
Mailing Address - Fax:951-658-7140
Practice Address - Street 1:790 S STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4924
Practice Address - Country:US
Practice Address - Phone:951-654-6062
Practice Address - Fax:951-602-8195
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5206142225400000X, 172A00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No172V00000XOther Service ProvidersCommunity Health Worker