Provider Demographics
NPI:1750160933
Name:SMITH, PATRICIA ALICE (LDO)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ALICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-3677
Mailing Address - Country:US
Mailing Address - Phone:706-632-9516
Mailing Address - Fax:
Practice Address - Street 1:WALMART
Practice Address - Street 2:97 COMMERCE DRIVE
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30512
Practice Address - Country:US
Practice Address - Phone:706-632-9516
Practice Address - Fax:706-632-9522
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1850156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician