Provider Demographics
NPI:1427767557
Name:VISNIC, SAMUEL J (MT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:VISNIC
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28822 OLD TOWN FRONT ST STE 306
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2723
Mailing Address - Country:US
Mailing Address - Phone:424-442-0663
Mailing Address - Fax:
Practice Address - Street 1:28822 OLD TOWN FRONT ST STE 306
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2723
Practice Address - Country:US
Practice Address - Phone:424-442-0663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist