Healthcare Provider Details

I. General information

NPI: 1902742471
Provider Name (Legal Business Name): SAMANTHA ROSE BARAJAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S 900 E
MARION IN
46953-9629
US

IV. Provider business mailing address

270 E BRAGG AVE
UPLAND IN
46989-9183
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-1214
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003063A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: