MEDICARE: SAMANTHA J VISCO ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL 3696	FL

General Provider Information

NPI Number	:	1104954809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA J VISCO ATC

Provider Business Mailing Address
First Line	:	1049 CHATHAM PINES CIR APT 307
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5247
Country	:	US
Telephone Number	:	404-217-6572
Fax Number	:	407-823-6744

Provider Business Practice Location Address
First Line	:	4180 N ORION BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32816-8029
Country	:	US
Telephone Number	:	407-823-0095
Fax Number	:	407-823-6744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	03/18/2015

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