Healthcare Provider Details

I. General information

NPI: 1386395028
Provider Name (Legal Business Name): LARRY SMITH RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4251 W DICKMAN RD APT 3C
SPRINGFIELD MI
49037-7585
US

IV. Provider business mailing address

4251 W DICKMAN RD APT 3C
SPRINGFIELD MI
49037-7585
US

V. Phone/Fax

Practice location:
  • Phone: 989-482-8034
  • Fax:
Mailing address:
  • Phone: 989-482-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number4401002743
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: