Basic Information
| Provider Information | |||||||||
| NPI: | 1790725414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITHDEAL | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RKT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 CROCKETT LN | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376435967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236767785 | ||||||||
| FaxNumber: | 4239793618 | ||||||||
| Practice Location | |||||||||
| Address1: | JAMES QUILLEN VAMC | ||||||||
| Address2: | BLD 200 RMS(117) | ||||||||
| City: | MOUTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | 4239793618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 226300000X | 1374 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Kinesiotherapist |
No ID Information.