Healthcare Provider Details

I. General information

NPI: 1407612807
Provider Name (Legal Business Name): GRAYSON SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 CENTRAL AVE
DEMOREST GA
30535-5252
US

IV. Provider business mailing address

1009 BALDWIN HEIGHTS RD
BALDWIN GA
30511-2962
US

V. Phone/Fax

Practice location:
  • Phone: 706-778-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT004695
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: