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General NPI Number Information
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NPI Number | 1538572730
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Entity Type | Individual
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Provider Name | JERRY SMITH
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Gender | Male
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Dates
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Enumeration Date | 06/04/2014
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Last Update Date | 06/04/2014
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Provider Practice Location Address
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Address Line | 50 TANGLEWOOD DR
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City | DAWSONVILLE
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State | GA
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Zip | 30534-8140
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Country | US
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Telephone | 706-867-0106
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Fax | 706-864-3368
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Provider Business Mailing Address
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Address Line | 50 TANGLEWOOD DR
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City | DAWSONVILLE
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State | GA
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Zip | 30534-8140
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Country | US
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Telephone | 706-867-0106
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Fax | 706-864-3368
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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 | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | PCH005362
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License Number State | GA
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