Provider Demographics
NPI:1033212352
Name:SMITH, VINCENT (PT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:8745 BLACKBIRD LANE
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-0273
Mailing Address - Country:US
Mailing Address - Phone:740-246-5843
Mailing Address - Fax:740-246-6480
Practice Address - Street 1:8745 BLACKBIRD LN
Practice Address - Street 2:
Practice Address - City:THORNVILLE
Practice Address - State:OH
Practice Address - Zip Code:43076-9515
Practice Address - Country:US
Practice Address - Phone:740-246-5843
Practice Address - Fax:740-246-6480
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSM0870882Medicare PIN