Provider Demographics
NPI:1659434900
Name:SMYLE, LAWRENCE (PT)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:SMYLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3635
Mailing Address - Country:US
Mailing Address - Phone:650-588-9668
Mailing Address - Fax:415-839-3077
Practice Address - Street 1:443 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3635
Practice Address - Country:US
Practice Address - Phone:650-588-9668
Practice Address - Fax:415-839-3077
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA611781300OtherACS
CACA110841Medicare Oscar/Certification