MEDICARE: VIDA TYRESE 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	172A00000X	Driver		VA
2	172A00000X	Driver

General Provider Information

NPI Number	:	1982326401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIDA TYRESE SMITH

Provider Business Mailing Address
First Line	:	20 ROSEWOOD LN
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-5414
Country	:	US
Telephone Number	:	180-439-3241
Fax Number	:	804-800-4066

Provider Business Practice Location Address
First Line	:	20 ROSEWOOD LN
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-5414
Country	:	US
Telephone Number	:	180-439-3241
Fax Number	:	804-800-4066

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

Provider Enumeration Date	:	09/12/2022
Last Update Date	:	09/12/2022

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Directions to “ VIDA TYRESE SMITH ” Practice Location

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