Healthcare Provider Details

I. General information

NPI: 1184055196
Provider Name (Legal Business Name): SAMANTHA HAINLINE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 ARROWHEAD DR APT 3B
MERRILLVILLE IN
46410-5189
US

IV. Provider business mailing address

2055 ARROWHEAD DR APT 3B
MERRILLVILLE IN
46410-5189
US

V. Phone/Fax

Practice location:
  • Phone: 309-502-9117
  • Fax:
Mailing address:
  • Phone: 309-502-9117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002074A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: