Provider Demographics
NPI:1558097428
Name:SMOLTINO, KATHRYN JEANNINE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEANNINE
Last Name:SMOLTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-7595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-7595
Practice Address - Country:US
Practice Address - Phone:803-532-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1063156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063OtherSC OPTICIANS LICENSE