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General NPI Number Information
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NPI Number | 1194614990
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Entity Type | Individual
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Provider Name | SAMANTHA LAROSE
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Gender | Female
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Dates
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Enumeration Date | 06/30/2025
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 32 CAMPUS DR MISSOULA MT 59812
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City | MISSOULA
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State | MT
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Zip | 59812-0001
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Country | US
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Telephone | 140-624-3535
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Fax |
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Provider Business Mailing Address
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Address Line | 614 N 3RD ST W APT 302
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City | MISSOULA
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State | MT
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Zip | 59802-3132
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Country | US
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Telephone | 208-830-9661
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | MT
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