Provider Demographics
NPI:1821210162
Name:SMITH, CORNELL
Entity Type:Individual
Prefix:
First Name:CORNELL
Middle Name:
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 1:6623 RENFRO DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-5951
Mailing Address - Country:US
Mailing Address - Phone:832-969-4870
Mailing Address - Fax:
Practice Address - Street 1:6623 RENFRO DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-5951
Practice Address - Country:US
Practice Address - Phone:832-969-4870
Practice Address - Fax:281-232-1949
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2054358225200000X
TX11349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No111N00000XChiropractic ProvidersChiropractor