Provider Demographics
NPI:1295382109
Name:SMITH, LATEYA
Entity Type:Individual
Prefix:
First Name:LATEYA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CLUSTERS CT # 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4831
Mailing Address - Country:US
Mailing Address - Phone:803-233-7554
Mailing Address - Fax:
Practice Address - Street 1:4401 BAILEY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7438
Practice Address - Country:US
Practice Address - Phone:717-472-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1147251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty