Healthcare Provider Details

I. General information

NPI: 1093413775
Provider Name (Legal Business Name): FREDDIE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 W LAMAR RD APT 44
GLENDALE AZ
85303-2721
US

IV. Provider business mailing address

8101 W LAMAR RD APT 44
GLENDALE AZ
85303-2721
US

V. Phone/Fax

Practice location:
  • Phone: 602-425-3188
  • Fax:
Mailing address:
  • Phone: 602-425-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: