Healthcare Provider Details

I. General information

NPI: 1609703578
Provider Name (Legal Business Name): ROBERT L SMITH II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 BIG CREEK RD
WAYNE WV
25570-8531
US

IV. Provider business mailing address

1323 BIG CREEK RD
WAYNE WV
25570-8531
US

V. Phone/Fax

Practice location:
  • Phone: 681-203-1898
  • Fax:
Mailing address:
  • Phone: 681-888-3373
  • Fax: 681-888-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number39605
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: