Provider Demographics
NPI:1144790627
Name:SMITH, THEODORE ROOSEVELT (LPN)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ROOSEVELT
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 EZZARD CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45214-2525
Mailing Address - Country:US
Mailing Address - Phone:513-381-6672
Mailing Address - Fax:
Practice Address - Street 1:830 EZZARD CHARLES DRIVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214
Practice Address - Country:US
Practice Address - Phone:513-381-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.168854.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse