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General NPI Number Information
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NPI Number | 1649762386
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Entity Type | Individual
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Provider Name | LORRAINE E SMITH ATC
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Gender | Female
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Dates
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Enumeration Date | 05/30/2018
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Last Update Date | 05/30/2018
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Provider Practice Location Address
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Address Line | 1313 W MAIN ST
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City | MASCOUTAH
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State | IL
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Zip | 62258-1065
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Country | US
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Telephone | 618-566-8523
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Fax |
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Provider Business Mailing Address
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Address Line | 9764 DRUM HILL RD
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City | MASCOUTAH
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State | IL
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Zip | 62258-4528
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Country | US
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Telephone | 217-473-6963
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.003851
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License Number State | IL
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