Healthcare Provider Details

I. General information

NPI: 1477529881
Provider Name (Legal Business Name): ERIC STEPHEN SMITH LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

210 E IOWA AVE
FOUNTAIN CO
80817-2204
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4073
  • Fax: 719-526-7676
Mailing address:
  • Phone: 719-322-9542
  • Fax: 719-526-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number33576
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: