Healthcare Provider Details

I. General information

NPI: 1487573945
Provider Name (Legal Business Name): BROC SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WESTWOOD MEDICAL PARK
BLUEFIELD VA
24605-2003
US

IV. Provider business mailing address

6421 COUNTRY RD
CYCLONE WV
24827-9454
US

V. Phone/Fax

Practice location:
  • Phone: 276-322-5439
  • Fax:
Mailing address:
  • Phone: 276-322-5439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberC2464
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: