Provider Demographics
NPI:1528243508
Name:GLADYS REA SMITH
Entity type:Organization
Organization Name:GLADYS REA SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-461-7534
Mailing Address - Street 1:50 S PICKETT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7207
Mailing Address - Country:US
Mailing Address - Phone:703-461-7534
Mailing Address - Fax:
Practice Address - Street 1:50 S PICKETT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7207
Practice Address - Country:US
Practice Address - Phone:703-461-7534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC18127335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0668390001Medicare NSC