Healthcare Provider Details

I. General information

NPI: 1043035686
Provider Name (Legal Business Name): NICHOLAS KENNETH SMYTHE III PH.D. IN PROGRESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D.L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

215 EAGLE LNDG
ENTERPRISE AL
36330-8659
US

V. Phone/Fax

Practice location:
  • Phone: 334-390-1795
  • Fax:
Mailing address:
  • Phone: 334-390-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: