Provider Demographics
NPI:1376939553
Name:SMELSER, MONGKON (LMT)
Entity Type:Individual
Prefix:
First Name:MONGKON
Middle Name:
Last Name:SMELSER
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:PO BOX 5667
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-5667
Mailing Address - Country:US
Mailing Address - Phone:228-283-5083
Mailing Address - Fax:
Practice Address - Street 1:12603 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-7420
Practice Address - Country:US
Practice Address - Phone:228-283-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS823172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist