Healthcare Provider Details

I. General information

NPI: 1215998182
Provider Name (Legal Business Name): JOSHUA CAMILLE SMART LATC, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BIRDSEYE AVE
CARIBOU ME
04736-1669
US

IV. Provider business mailing address

22 BIRDSEYE AVE
CARIBOU ME
04736-1669
US

V. Phone/Fax

Practice location:
  • Phone: 207-492-0346
  • Fax:
Mailing address:
  • Phone: 207-227-3689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number070502046
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberMT3902
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: