Provider Demographics
NPI:1770025199
Name:SMITH, MARTIN LUTHER SR
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LUTHER
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MOCKINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-3123
Mailing Address - Country:US
Mailing Address - Phone:803-543-8936
Mailing Address - Fax:866-806-7982
Practice Address - Street 1:2000 MOCKINGBIRD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-3123
Practice Address - Country:US
Practice Address - Phone:803-543-8936
Practice Address - Fax:866-806-7982
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0198374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide