MEDICARE: MISS LAUREN ELIZABETH SMITH AT, 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	2601001124	MI
2	208100000X	Physical Medicine & Rehabilitation Physician	5501017854	MI

General Provider Information

NPI Number	:	1467825489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LAUREN ELIZABETH SMITH AT, ATC

Provider Business Mailing Address
First Line	:	610 LAFAYETTE AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1660
Country	:	US
Telephone Number	:	269-760-5085
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 LAFAYETTE AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1660
Country	:	US
Telephone Number	:	269-760-5085
Fax Number	:

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

Provider Enumeration Date	:	11/12/2015
Last Update Date	:	10/03/2018

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