Provider Demographics
NPI:1265062343
Name:SMITH, KELVIN JR (LO, CO)
Entity type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:LO, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350C FORTUNE TER # 331
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2980
Mailing Address - Country:US
Mailing Address - Phone:843-209-0417
Mailing Address - Fax:
Practice Address - Street 1:989 E PARK DR STE C
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2803
Practice Address - Country:US
Practice Address - Phone:717-564-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO006148OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, & PEDORTHICS