Provider Demographics
NPI:1780241505
Name:SMITH CLINIC LLC
Entity type:Organization
Organization Name:SMITH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-261-9500
Mailing Address - Street 1:5116 NORTHWIND BLVD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7672
Mailing Address - Country:US
Mailing Address - Phone:229-261-9500
Mailing Address - Fax:229-261-9501
Practice Address - Street 1:5116 NORTHWIND BLVD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7672
Practice Address - Country:US
Practice Address - Phone:229-261-9500
Practice Address - Fax:229-261-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty