Healthcare Provider Details

I. General information

NPI: 1780151555
Provider Name (Legal Business Name): SAMANTHA LEE KOCIEMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 17TH AVE E
SHAKOPEE MN
55379-3372
US

IV. Provider business mailing address

1755 17TH AVE E
SHAKOPEE MN
55379-3372
US

V. Phone/Fax

Practice location:
  • Phone: 952-445-5250
  • Fax:
Mailing address:
  • Phone: 952-445-5250
  • Fax: 952-445-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: