Healthcare Provider Details

I. General information

NPI: 1689295123
Provider Name (Legal Business Name): CHRISTOPHER RICHARD SMITH LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

154 BROCK DR
SALTILLO MS
38866-9187
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4517
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: