Provider Demographics
NPI:1457873051
Name:WICHAEL, SAMUEL (LAT, ATC, CES)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WICHAEL
Suffix:
Gender:M
Credentials:LAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 MISSION BAY BLVD APT 130
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1997
Mailing Address - Country:US
Mailing Address - Phone:303-217-1789
Mailing Address - Fax:
Practice Address - Street 1:4422 KNIGHTS VICTORY WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-8019
Practice Address - Country:US
Practice Address - Phone:407-823-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer