Provider Demographics
NPI:1033386495
Name:SAMSANOVICH, VYACHESLAV
Entity Type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:
Last Name:SAMSANOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18663 VENTURA BLVD
Mailing Address - Street 2:SUITE #108
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4162
Mailing Address - Country:US
Mailing Address - Phone:818-881-1485
Mailing Address - Fax:
Practice Address - Street 1:18663 VENTURA BLVD
Practice Address - Street 2:SUITE #108
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4162
Practice Address - Country:US
Practice Address - Phone:818-881-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL4691156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician