MEDICARE: DEVON T SMITH MAED, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	1589	NC

General Provider Information

NPI Number	:	1386077444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON T SMITH MAED, LAT, ATC

Provider Business Mailing Address
First Line	:	9305 S VICKSBURG PARK CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-7751
Country	:	US
Telephone Number	:	775-354-4243
Fax Number	:

Provider Business Practice Location Address
First Line	:	9305 S VICKSBURG PARK CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-7751
Country	:	US
Telephone Number	:	775-354-4243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	03/03/2014

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