MEDICARE: ELIZABETH SMITH

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1821492034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH SMITH

Provider Business Mailing Address
First Line	:	250 NORTH AVE
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30601-2244
Country	:	US
Telephone Number	:	706-389-6790
Fax Number	:	706-389-6760

Provider Business Practice Location Address
First Line	:	1227 DALE DR
Second Line	:
City	:	MONROE
State	:	GA
Zip	:	30656-3500
Country	:	US
Telephone Number	:	706-389-6790
Fax Number	:	706-389-6760

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

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/17/2014

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