Healthcare Provider Details

I. General information

NPI: 1316325442
Provider Name (Legal Business Name): KEVIN SMITH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35640 W MICHIGAN AVE
WAYNE MI
48184-1628
US

IV. Provider business mailing address

320 TOLEDO ST
ADRIAN MI
49221-2831
US

V. Phone/Fax

Practice location:
  • Phone: 734-729-7792
  • Fax: 734-729-7938
Mailing address:
  • Phone: 724-770-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: