Provider Demographics
NPI:1851572051
Name:SMITH, KENNETH B
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
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 1:2191 NORTHLAKE PKWY
Mailing Address - Street 2:BLDG. #11, SUITE-J
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4166
Mailing Address - Country:US
Mailing Address - Phone:770-908-5666
Mailing Address - Fax:770-908-5675
Practice Address - Street 1:2191 NORTHLAKE PKWY
Practice Address - Street 2:BLDG. #11, SUITE-J
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4166
Practice Address - Country:US
Practice Address - Phone:770-908-5666
Practice Address - Fax:770-908-5675
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies