=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205604352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SMITH XPERIENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2023
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 MEADOW LAKE DR
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23518-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-816-7034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8036 CRESCENT RD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23505-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-816-7034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER/HAIRSTYLIST
-----------------------------------------------------
Name | RODRICA SMITH
-----------------------------------------------------
Credential | COMETOLOGIST
-----------------------------------------------------
Telephone | 175-781-6703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------