Healthcare Provider Details

I. General information

NPI: 1275281362
Provider Name (Legal Business Name): COURTLAND K SMITH LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W TOWN PL STE 22
ST AUGUSTINE FL
32092-3103
US

IV. Provider business mailing address

8538 OCALA AVE
JACKSONVILLE FL
32220-1536
US

V. Phone/Fax

Practice location:
  • Phone: 904-680-7328
  • Fax:
Mailing address:
  • Phone: 904-382-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA98858
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: