Healthcare Provider Details

I. General information

NPI: 1669444089
Provider Name (Legal Business Name): JAMES ELLIS SMITH III MS, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NH-100 BREWSTER BLVD
CAMP LEJEUNE NC
28547
US

IV. Provider business mailing address

311 GOV SAFFORD LN
EMERALD ISLE NC
28594-2366
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4050
  • Fax:
Mailing address:
  • Phone: 252-626-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number933833
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: