Healthcare Provider Details

I. General information

NPI: 1124983713
Provider Name (Legal Business Name): ROBERT SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10127 CLIFTON FORGE AVE
LAS VEGAS NV
89148-4539
US

IV. Provider business mailing address

10127 CLIFTON FORGE AVE
LAS VEGAS NV
89148-4539
US

V. Phone/Fax

Practice location:
  • Phone: 702-704-5889
  • Fax:
Mailing address:
  • Phone: 702-704-5889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: