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NPI Code Detail

MEDICARE: KENNETH SMOOT AT, ATC

MEDICARE: KENNETH SMOOT 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
12255A2300XAthletic Trainer2601001088MI

General Provider Information

NPI Number : 1922814375
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH SMOOT AT, ATC
Provider Business Mailing Address
First Line : 33900 HARPER AVE STE 104
Second Line :
City : CLINTON TWP
State : MI
Zip : 48035-4258
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 51635 10 MILE RD
Second Line :
City : SOUTH LYON
State : MI
Zip : 48178-9720
Country : US
Telephone Number : 248-278-1072
Fax Number : 248-278-1073
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/09/2024
Last Update Date : 12/12/2024

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Directions to “ KENNETH SMOOT AT, ATC” Practice Location

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