Provider Demographics
NPI:1629052204
Name:SMITH, TERRY LEE (CSA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TRILLIUM WAY
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8727
Mailing Address - Country:US
Mailing Address - Phone:606-526-8122
Mailing Address - Fax:
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8727
Practice Address - Country:US
Practice Address - Phone:606-528-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA111246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYSA111OtherCERTIFIED SURGICAL ASSISTANT LICENSE