Provider Demographics
NPI:1124297338
Name:ROB SMITH
Entity type:Organization
Organization Name:ROB SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-982-4451
Mailing Address - Street 1:736 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4410
Mailing Address - Country:US
Mailing Address - Phone:810-982-4451
Mailing Address - Fax:810-982-8539
Practice Address - Street 1:736 LAPEER AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4410
Practice Address - Country:US
Practice Address - Phone:810-982-4451
Practice Address - Fax:810-982-8539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540G410540OtherBCBS
1186480001Medicare NSC