Healthcare Provider Details

I. General information

NPI: 1730652355
Provider Name (Legal Business Name): KIMBERLY SMITH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM SMITH PTA

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W CLAY RD
VERSAILLES MO
65084-1177
US

IV. Provider business mailing address

1682 CUP TREE RD
GRAVOIS MILLS MO
65037-6930
US

V. Phone/Fax

Practice location:
  • Phone: 573-280-3321
  • Fax: 573-539-3066
Mailing address:
  • Phone: 573-280-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2006038459
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: