Healthcare Provider Details

I. General information

NPI: 1316454283
Provider Name (Legal Business Name): MR. JOHN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 02/17/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 E GLENWOOD AVE
AKRON OH
44310-3850
US

IV. Provider business mailing address

365 MALACCA ST
AKRON OH
44305-3659
US

V. Phone/Fax

Practice location:
  • Phone: 330-957-4599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberSM821261
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code1744G0900X
TaxonomyGraphics Designer
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: