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General NPI Number Information
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NPI Number | 1215359310
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Entity Type | Individual
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Provider Name | SAMANTHA BOLLICH CNIM
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Gender | Female
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Dates
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Enumeration Date | 01/09/2014
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Last Update Date | 11/11/2016
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Provider Practice Location Address
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Address Line | 860654 S 3430 RD
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City | CHANDLER
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State | OK
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Zip | 74834-7078
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Country | US
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Telephone | 979-248-9890
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Fax |
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Provider Business Mailing Address
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Address Line | 860654 S 3430 RD
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City | CHANDLER
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State | OK
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Zip | 74834-7078
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Country | US
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Telephone | 979-248-9890
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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 | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number | CNIM2768
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License Number State | TX
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