Healthcare Provider Details

I. General information

NPI: 1760965727
Provider Name (Legal Business Name): HEAVEN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19106 LONGVIEW AVE
MAPLE HEIGHTS OH
44137-1629
US

IV. Provider business mailing address

19106 LONGVIEW AVE
MAPLE HEIGHTS OH
44137-1629
US

V. Phone/Fax

Practice location:
  • Phone: 216-712-3527
  • Fax:
Mailing address:
  • Phone: 216-712-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: