Provider Demographics
NPI:1104297050
Name:EISENS, SAMUEL (ATC, LAT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:EISENS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 WINDING ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-4479
Mailing Address - Country:US
Mailing Address - Phone:336-213-0831
Mailing Address - Fax:
Practice Address - Street 1:901 S FLAGLER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-6505
Practice Address - Country:US
Practice Address - Phone:561-803-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 21692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer