Healthcare Provider Details

I. General information

NPI: 1346786092
Provider Name (Legal Business Name): KATIE OLINI MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 ROBERT M GRISSOM PKWY
MYRTLE BEACH SC
29577-6401
US

IV. Provider business mailing address

3827 MAYPOP CIR UNIT 317
MYRTLE BEACH SC
29588-1407
US

V. Phone/Fax

Practice location:
  • Phone: 843-445-2051
  • Fax:
Mailing address:
  • Phone: 732-778-2153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2011
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00214300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: