Provider Demographics
NPI:1801241286
Name:FAVREAU, SAMANTHA (DC)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-2220
Mailing Address - Country:US
Mailing Address - Phone:806-765-8443
Mailing Address - Fax:806-749-1181
Practice Address - Street 1:2630 26TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2220
Practice Address - Country:US
Practice Address - Phone:806-765-8443
Practice Address - Fax:806-749-1181
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor