1588075121 NPI number — DR. MATTHEW CHARLEW SMITLEY DAT, LAT, ATC

Table of content: DR. MATTHEW CHARLEW SMITLEY DAT, LAT, ATC (NPI 1588075121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588075121 NPI number — DR. MATTHEW CHARLEW SMITLEY DAT, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITLEY
Provider First Name:
MATTHEW
Provider Middle Name:
CHARLEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DAT, LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588075121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 OPAL BROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37643-7462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 PERIMETER DR # MS 2401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83844-7462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-885-0349
Provider Business Practice Location Address Fax Number:
208-885-5929
Provider Enumeration Date:
05/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  LAT-2518 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , with the licence number: AT-642 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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