1922398650 NPI number — MR. PHILLIP MATTHEW SMITH OCCUPATIONAL THERAPY

Table of content: MR. PHILLIP MATTHEW SMITH OCCUPATIONAL THERAPY (NPI 1922398650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922398650 NPI number — MR. PHILLIP MATTHEW SMITH OCCUPATIONAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
PHILLIP
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OCCUPATIONAL THERAPY
Provider Gender Code:
M

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:
1922398650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 SHED ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71111
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:
3808 KILPATRICK DR
Provider Second Line Business Practice Location Address:
NORTHWEST RECOURCE CENTER
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-741-2802
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OTA.Z.20243 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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