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General NPI Number Information
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NPI Number | 1588955744
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Entity Type | Organization
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Legal Business Name | SMOKY MOUNTAIN UROLOGY, INC
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Dates
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Enumeration Date | 04/22/2011
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Last Update Date | 04/22/2011
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Provider Practice Location Address
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Address Line | 1334 ASHEVILLE HWY
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City | HENDERSONVILLE
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State | NC
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Zip | 28791-3414
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Country | US
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Telephone | 828-698-0896
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Fax | 828-698-9532
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Provider Business Mailing Address
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Address Line | 1334 ASHEVILLE HWY
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City | HENDERSONVILLE
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State | NC
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Zip | 28791-3414
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Country | US
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Telephone | 828-698-0896
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Fax | 828-698-9532
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Authorized Official
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Title or Position | CEO
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Name | DR. RUSTAN JOEL VAN WYK
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Credential | D.O.
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Telephone | 828-698-0896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | BV7069330
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License Number State | NC
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