Provider Demographics
NPI:1285211763
Name:SMITH, JUSTIN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 NW 1ST WAY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-5214
Mailing Address - Country:US
Mailing Address - Phone:803-634-8985
Mailing Address - Fax:
Practice Address - Street 1:1680 NW 1ST WAY
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-5214
Practice Address - Country:US
Practice Address - Phone:803-634-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA96889225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist