Provider Demographics
NPI:1407279433
Name:SMITH, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OWNER
Mailing Address - Street 1:PO BOX 1882
Mailing Address - Street 2:103 TENTH ST.
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-1882
Mailing Address - Country:US
Mailing Address - Phone:318-307-9937
Mailing Address - Fax:318-649-2387
Practice Address - Street 1:103 10TH ST
Practice Address - Street 2:103 TENTH ST.
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-3306
Practice Address - Country:US
Practice Address - Phone:318-307-9937
Practice Address - Fax:318-649-2387
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver