Provider Demographics
NPI:1114323987
Name:AMITY LYNN SMITH, PLLC
Entity Type:Organization
Organization Name:AMITY LYNN SMITH, PLLC
Other - Org Name:REVOLUTION WELLNESS AND PREVENTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMITY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-2837
Mailing Address - Street 1:601 ZENA RUCKER RD
Mailing Address - Street 2:STE 105
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6386
Mailing Address - Country:US
Mailing Address - Phone:817-466-2837
Mailing Address - Fax:817-488-6335
Practice Address - Street 1:601 ZENA RUCKER RD
Practice Address - Street 2:STE 105
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6386
Practice Address - Country:US
Practice Address - Phone:817-466-2837
Practice Address - Fax:817-488-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9802261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty