1104078708 NPI number — MR. LARRY DARNELL SMITH PHYSICAL THERAPIST

Table of content: MR. LARRY DARNELL SMITH PHYSICAL THERAPIST (NPI 1104078708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104078708 NPI number — MR. LARRY DARNELL SMITH PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LARRY
Provider Middle Name:
DARNELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1104078708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
914 TAMARACK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32303-4649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-212-8279
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
914 TAMARACK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32303-4649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-212-8279
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2008

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: 225100000X , with the licence number:  PT10110 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114460200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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