Provider Demographics
NPI:1245784230
Name:SAMLUK, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SAMLUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CALIFORNIA STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154
Mailing Address - Country:US
Mailing Address - Phone:800-456-5857
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PLACE STE. #175
Practice Address - Street 2:DELTA HEALTHCARE PROVIDERS
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75234
Practice Address - Country:US
Practice Address - Phone:866-221-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1279436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist