Provider Demographics
NPI:1366678369
Name:SMITH, JUSTIN ADAM (ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ADAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:OWENS FIELD HOUSE
Mailing Address - Street 2:135 JACK BRANCH DRIVE
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28608-0001
Mailing Address - Country:US
Mailing Address - Phone:828-262-6265
Mailing Address - Fax:828-262-7099
Practice Address - Street 1:OWENS FIELD HOUSE
Practice Address - Street 2:135 JACK BRANCH DRIVE
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28608-0001
Practice Address - Country:US
Practice Address - Phone:828-262-6265
Practice Address - Fax:828-262-7099
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer