Provider Demographics
NPI:1982376521
Name:SMITH, CARL EDWARD JR (CRRA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:EDWARD
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:CRRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2107
Mailing Address - Country:US
Mailing Address - Phone:386-319-6160
Mailing Address - Fax:
Practice Address - Street 1:527 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2107
Practice Address - Country:US
Practice Address - Phone:386-319-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIND-877173261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder