Provider Demographics
NPI:1194264655
Name:SMITH, ELLIOTT ISAAC (LMT)
Entity type:Individual
Prefix:MR
First Name:ELLIOTT
Middle Name:ISAAC
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:609 VALLE DE BRAVO PL
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-4700
Mailing Address - Country:US
Mailing Address - Phone:915-245-9741
Mailing Address - Fax:
Practice Address - Street 1:125 N KENAZO AVE
Practice Address - Street 2:STE I & J
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-5404
Practice Address - Country:US
Practice Address - Phone:915-245-9741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122956225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist