Provider Demographics
NPI:1215359310
Name:BOLLICH, SAMANTHA (CNIM)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BOLLICH
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNIM
Mailing Address - Street 1:860654 S 3430 RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-7078
Mailing Address - Country:US
Mailing Address - Phone:979-248-9890
Mailing Address - Fax:
Practice Address - Street 1:860654 S 3430 RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-7078
Practice Address - Country:US
Practice Address - Phone:979-248-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCNIM2768246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic