Provider Demographics
NPI:1225709785
Name:SMITH, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
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 385
Mailing Address - Street 2:
Mailing Address - City:LORADO
Mailing Address - State:WV
Mailing Address - Zip Code:25630-0385
Mailing Address - Country:US
Mailing Address - Phone:304-687-8853
Mailing Address - Fax:
Practice Address - Street 1:168 PICTURE PERFECT DRIVE
Practice Address - Street 2:
Practice Address - City:LUNDALE
Practice Address - State:WV
Practice Address - Zip Code:25630
Practice Address - Country:US
Practice Address - Phone:304-687-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF290978374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide