Healthcare Provider Details

I. General information

NPI: 1497681530
Provider Name (Legal Business Name): JIMIL SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 CAROLINA AVE
BLUEFIELD WV
24701-2720
US

IV. Provider business mailing address

1121 CAROLINA AVE
BLUEFIELD WV
24701-2720
US

V. Phone/Fax

Practice location:
  • Phone: 304-888-8180
  • Fax:
Mailing address:
  • Phone: 304-888-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: