Healthcare Provider Details

I. General information

NPI: 1619704335
Provider Name (Legal Business Name): MARINA VANDERSLICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WHEAT ST
COLUMBIA SC
29201-4347
US

IV. Provider business mailing address

903 SYCAMORE TRCE
LOWELL AR
72745-9064
US

V. Phone/Fax

Practice location:
  • Phone: 479-419-0827
  • Fax:
Mailing address:
  • Phone: 479-419-0827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: