Basic Information
| Provider Information | |||||||||
| NPI: | 1366171811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKEK | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| OtherLastName: | SOLTIS | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10465 LARKSPUR AVE | ||||||||
| Address2: | |||||||||
| City: | GROSSE ILE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481381603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084207266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10912 WAYNE RD | ||||||||
| Address2: | |||||||||
| City: | ROMULUS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481741471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349557000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501302102 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.