Healthcare Provider Details

I. General information

NPI: 1861582892
Provider Name (Legal Business Name): S. SCOTT SMITH I OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 W TIETAN ST
WALLA WALLA WA
99362-4363
US

IV. Provider business mailing address

5229 154 A AVE
EDMONTON ALBERTA
T5Y 2S5
CA

V. Phone/Fax

Practice location:
  • Phone: 509-525-2100
  • Fax: 509-522-0313
Mailing address:
  • Phone: 780-476-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003239
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: