=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326701756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOLOMON SMITH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12411 VETERANS MEMORIAL HWY STE 3
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-724-1027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 PLEASANT HILL RD APT 1123
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-4180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------