Healthcare Provider Details

I. General information

NPI: 1083939789
Provider Name (Legal Business Name): HERBERT GEORGE SMITH JR. L.P.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 LITTLE RD SUITE 102
TRINITY FL
34655-1715
US

IV. Provider business mailing address

4109 LITTLE RD SUITE 102
TRINITY FL
34655-1715
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-6978
  • Fax: 727-807-3331
Mailing address:
  • Phone: 727-645-6978
  • Fax: 727-807-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberPOR81
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPOR81
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: