Provider Demographics
NPI:1679731186
Name:SMITH, KEITH EARL (OTR L)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EARL
Last Name:SMITH
Suffix:
Gender:M
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3597
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28564-3597
Mailing Address - Country:US
Mailing Address - Phone:252-883-8662
Mailing Address - Fax:
Practice Address - Street 1:2600 OLD CHERRY POINT RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-6778
Practice Address - Country:US
Practice Address - Phone:252-637-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2603313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility