Provider Demographics
NPI:1881052439
Name:SMITH, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S OAKLAND AVE
Mailing Address - Street 2:STE 6444
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0837
Mailing Address - Country:US
Mailing Address - Phone:336-747-3479
Mailing Address - Fax:
Practice Address - Street 1:450 W HANES MILL RD
Practice Address - Street 2:201
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9141
Practice Address - Country:US
Practice Address - Phone:336-747-3479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27780134172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC27780134OtherNON EMERGENCY MEDICAL TRANSPORTATION