Basic Information
| Provider Information | |||||||||
| NPI: | 1376931931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHILLACE | ||||||||
| FirstName: | VIVIANI | ||||||||
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| Credential: | A.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 S LANE ST | ||||||||
| Address2: | |||||||||
| City: | BUCYRUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448202319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195626686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 351 S LANE ST | ||||||||
| Address2: | |||||||||
| City: | BUCYRUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448202319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195626686 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2015 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 004111 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.