Provider Demographics
NPI:1326011883
Name:SMITH, WADE RAYMOND (ATC/L)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:RAYMOND
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 NW GWEN LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3216
Mailing Address - Country:US
Mailing Address - Phone:386-719-6879
Mailing Address - Fax:
Practice Address - Street 1:4367 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4828
Practice Address - Country:US
Practice Address - Phone:386-758-1841
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 1072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04020-17-0232-000Medicare ID - Type UnspecifiedDURABLE MEDICAL EQUIPMENT