MEDICARE: OKIDA SMILES, LLC

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	251E00000X	Home Health Agency	0001160918	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0156115021	OTHER	VA	API

General Provider Information

NPI Number	:	1851536213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKIDA SMILES, LLC

Provider Business Mailing Address
First Line	:	9507 HULL STREET RD
Second Line	:	SUITE G-1
City	:	RICHMOND
State	:	VA
Zip	:	23236-1476
Country	:	US
Telephone Number	:	804-837-2196
Fax Number	:

Provider Business Practice Location Address
First Line	:	9507 HULL STREET RD
Second Line	:	SUITE G-1
City	:	RICHMOND
State	:	VA
Zip	:	23236-1476
Country	:	US
Telephone Number	:	804-837-2196
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. WILLIAM SIMON
Credential	:
Telephone Number	:	804-837-2196

Provider Enumeration Date	:	12/12/2008
Last Update Date	:	12/15/2008

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