Basic Information
| Provider Information | |||||||||
| NPI: | 1578944575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | REWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 556 DOUGLAS AVE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405081072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599136661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592584000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 2550 | KY | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.