Provider Demographics
NPI:1538826227
Name:SMITH, CLIFTON WAYNE JR
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:WAYNE
Last Name:SMITH
Suffix:JR
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 1:402 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25015-1504
Mailing Address - Country:US
Mailing Address - Phone:207-610-2632
Mailing Address - Fax:
Practice Address - Street 1:402 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:WV
Practice Address - Zip Code:25015-1504
Practice Address - Country:US
Practice Address - Phone:207-610-2632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant