Provider Demographics
NPI:1801333471
Name:SMITH, BRANDON (ATC, LAT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 EAGLE CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8022
Mailing Address - Country:US
Mailing Address - Phone:704-677-5746
Mailing Address - Fax:
Practice Address - Street 1:133 EAGLE CT
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8022
Practice Address - Country:US
Practice Address - Phone:704-677-5746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2000022228OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER
NCLAT-2878OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS