Provider Demographics
NPI:1477966422
Name:SMITH, CRAIG ANTHONY (LAT,ATC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ANTHONY
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 S RACE ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5335
Mailing Address - Country:US
Mailing Address - Phone:765-506-7183
Mailing Address - Fax:
Practice Address - Street 1:4623 S RACE ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5335
Practice Address - Country:US
Practice Address - Phone:765-506-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002255A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer