Healthcare Provider Details

I. General information

NPI: 1346527330
Provider Name (Legal Business Name): MR. TIM M SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 GREENWOOD RD.
SHREVEPORT LA
71103
US

IV. Provider business mailing address

408 WEAVERS WAY
BOSSIER CITY LA
71111-2097
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4450
  • Fax:
Mailing address:
  • Phone: 318-617-6523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License NumberCEP.CE0198
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: