Provider Demographics
NPI:1891994117
Name:SMITH, RICHARD EDSON (LMT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 PONCE DE LEON DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-7874
Mailing Address - Country:US
Mailing Address - Phone:386-441-7126
Mailing Address - Fax:
Practice Address - Street 1:241 PONCE DE LEON DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-7874
Practice Address - Country:US
Practice Address - Phone:386-441-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0010916225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist