Provider Demographics
NPI:1063130243
Name:SMITH, ELISE VICTORIA MANBERT
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:VICTORIA MANBERT
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7338
Mailing Address - Country:US
Mailing Address - Phone:541-531-1911
Mailing Address - Fax:541-816-4939
Practice Address - Street 1:18 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7338
Practice Address - Country:US
Practice Address - Phone:541-531-1911
Practice Address - Fax:541-816-4939
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist