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General NPI Number Information
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NPI Number | 1538337431
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Entity Type | Organization
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Legal Business Name | CANDACE NICOLE SMITH
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Dates
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Enumeration Date | 02/13/2008
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Last Update Date | 06/29/2008
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Provider Practice Location Address
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Address Line | 1522 PORTER WAGONER BLVD STE 1
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City | WEST PLAINS
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State | MO
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Zip | 65775-1832
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Country | US
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Telephone | 417-256-6625
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Fax |
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Provider Business Mailing Address
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Address Line | 2119 ROSEMOOR ST
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City | WEST PLAINS
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State | MO
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Zip | 65775-4119
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CANDACE NICOLE SMITH
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Credential |
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Telephone | 417-257-9631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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