MEDICARE: SAMANTHA LYNN HOULE 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	AL4251	FL

General Provider Information

NPI Number	:	1588035539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LYNN HOULE ATC

Provider Business Mailing Address
First Line	:	4878 SAND STONE LN
Second Line	:	APT 108
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-8035
Country	:	US
Telephone Number	:	715-410-0880
Fax Number	:

Provider Business Practice Location Address
First Line	:	4878 SAND STONE LN
Second Line	:	APT 108
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-8035
Country	:	US
Telephone Number	:	715-410-0880
Fax Number	:

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

Provider Enumeration Date	:	10/16/2015
Last Update Date	:	10/16/2015

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