1558459297 NPI number — C. BROOKS SMITH M.D. & ASSOCIATES

Table of content: KELLEY LAYNE CARR DPT (NPI 1922083716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558459297 NPI number — C. BROOKS SMITH M.D. & ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C. BROOKS SMITH M.D. & ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558459297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 HILL BLVD UNIT 104
Provider Second Line Business Mailing Address:
UNIT 104
Provider Business Mailing Address City Name:
GRANBURY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76048-1482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 MEDICAL PLAZA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76048-5653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-573-5688
Provider Business Practice Location Address Fax Number:
817-573-5760
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
BROOKS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-573-5688

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J9921 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com