Healthcare Provider Details

I. General information

NPI: 1427389964
Provider Name (Legal Business Name): CODY WAYNE SMITH CST, CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W. ROSEDALE, SUITE 201
FORT WORTH TX
76104
US

IV. Provider business mailing address

7324 SOUTHWEST FWY STE 1550
HOUSTON TX
77074-2053
US

V. Phone/Fax

Practice location:
  • Phone: 817-885-7442
  • Fax: 817-885-7443
Mailing address:
  • Phone: 832-436-4273
  • Fax: 832-436-4273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberCERT. # 106121
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number106121
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: