=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649545286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMITHOTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 MARKET ST STE 4
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-653-8411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 MARKET ST SUITE 4
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-653-8411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED ORTHOTIST PROSTHETIST
-----------------------------------------------------
Name | MR. JOHAN MICHAEL SMITH
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 224-653-8411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 248000569
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------