=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679853907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN LEVI SMITH P.T., D.P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2011
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2918 PLEASANT GROVE RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-0064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-793-6135
-----------------------------------------------------
Fax | 903-793-0053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2918 PLEASANT GROVE RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-0064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-628-1214
-----------------------------------------------------
Fax | 903-347-2255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1192873
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------