=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790145423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMITH OPTOMETRIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2016
-----------------------------------------------------
Last Update Date | 06/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1502 E BROAD AVE STE A
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28379-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-997-7737
-----------------------------------------------------
Fax | 910-997-7058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1502 E BROAD AVE STE A
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28379-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-997-7737
-----------------------------------------------------
Fax | 910-997-7058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELVEN CONRAD SMITH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 910-997-7737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | 1267
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------