Provider Demographics
NPI:1124674163
Name:SMITH, RODERICK MALCOLM
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:MALCOLM
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FIR ST
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-2926
Mailing Address - Country:US
Mailing Address - Phone:276-690-8752
Mailing Address - Fax:276-386-2465
Practice Address - Street 1:125 FIR ST
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-2926
Practice Address - Country:US
Practice Address - Phone:276-690-8752
Practice Address - Fax:276-386-2465
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT65017143347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle