=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043035686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS KENNETH SMYTHE III PH.D. IN PROGRESS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2024
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 W D.L. INGRAM AVENUE, BLDG. 1408
-----------------------------------------------------
City | CANNON AFB
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-390-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 EAGLE LNDG
-----------------------------------------------------
City | ENTERPRISE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36330-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-390-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2472E0500X
-----------------------------------------------------
Taxonomy Name | EEG Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------