=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578066064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMEKKA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2018
-----------------------------------------------------
Last Update Date | 03/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5424 STRICKLAND AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33812-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-640-1291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 JEFFERSON AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLY LEGG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-640-1291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------