Healthcare Provider Details

I. General information

NPI: 1891734919
Provider Name (Legal Business Name): MAXINE M SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

7825 N GANNETT RD
SAGAMORE HILLS OH
44067-2921
US

V. Phone/Fax

Practice location:
  • Phone: 800-223-2273
  • Fax:
Mailing address:
  • Phone: 330-468-4062
  • Fax: 216-445-4356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD2726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: