Provider Demographics
NPI:1437864469
Name:SMITH, BRODY W
Entity Type:Individual
Prefix:
First Name:BRODY
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22951 HIGHWAY CC
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MO
Mailing Address - Zip Code:63465-1136
Mailing Address - Country:US
Mailing Address - Phone:660-216-9328
Mailing Address - Fax:
Practice Address - Street 1:22951 HIGHWAY CC
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MO
Practice Address - Zip Code:63465-1136
Practice Address - Country:US
Practice Address - Phone:660-216-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer