Provider Demographics
NPI:1790394310
Name:SMITH, KEVIN LEE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:SMITH
Suffix:
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:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-0761
Mailing Address - Country:US
Mailing Address - Phone:304-813-0153
Mailing Address - Fax:
Practice Address - Street 1:97 CULP DR
Practice Address - Street 2:
Practice Address - City:RIDGELEY
Practice Address - State:WV
Practice Address - Zip Code:26753-7407
Practice Address - Country:US
Practice Address - Phone:304-813-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant