Healthcare Provider Details

I. General information

NPI: 1760252613
Provider Name (Legal Business Name): SAMANTHA VACIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 COTTAGE HILL RD STE 400
MOBILE AL
36606-2913
US

IV. Provider business mailing address

24253 ALYDAR LOOP
DAPHNE AL
36526-0330
US

V. Phone/Fax

Practice location:
  • Phone: 251-235-2531
  • Fax:
Mailing address:
  • Phone: 251-235-2531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: