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General NPI Number Information
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NPI Number | 1306361076
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Entity Type | Individual
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Provider Name | TIMOTHY MICHAEL SMITH
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Gender | Male
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Dates
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Enumeration Date | 08/03/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 101 OKLAHOMA AVE
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City | DALE
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State | OK
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Zip | 74851-8222
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Country | US
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Telephone | 805-901-7119
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Fax |
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Provider Business Mailing Address
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Address Line | 101 OKLAHOMA AVE
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City | DALE
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State | OK
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Zip | 74851-8222
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Country | US
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Telephone | 805-901-7119
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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