Healthcare Provider Details

I. General information

NPI: 1629052204
Provider Name (Legal Business Name): TERRY LEE SMITH CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8727
US

IV. Provider business mailing address

1 TRILLIUM WAY
CORBIN KY
40701-8727
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-1212
  • Fax:
Mailing address:
  • Phone: 606-526-8122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA111
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: