Healthcare Provider Details

I. General information

NPI: 1104954809
Provider Name (Legal Business Name): SAMANTHA J VISCO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 N ORION BLVD
ORLANDO FL
32816-8029
US

IV. Provider business mailing address

1049 CHATHAM PINES CIR APT 307
WINTER SPRINGS FL
32708-5247
US

V. Phone/Fax

Practice location:
  • Phone: 407-823-0095
  • Fax: 407-823-6744
Mailing address:
  • Phone: 404-217-6572
  • Fax: 407-823-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 3696
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: