Provider Demographics
NPI:1578740783
Name:SMITH, THEODORE JAMES (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:STOCK SPORTS MEDICINE CLINIC
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-7818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:STOCK SPORTS MEDICINE CLINIC
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-7818
Practice Address - Country:US
Practice Address - Phone:603-526-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer