Healthcare Provider Details

I. General information

NPI: 1225744451
Provider Name (Legal Business Name): SAMIRA RAZAVI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 BOLLETTIERI BLVD
BRADENTON FL
34210-2211
US

IV. Provider business mailing address

101 3RD AVE W
BRADENTON FL
34205-8688
US

V. Phone/Fax

Practice location:
  • Phone: 941-524-3778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2-4943
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: