Provider Demographics
NPI:1902076235
Name:SMITH, MATHEW JAMES SR (LPN , CPS)
Entity Type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:JAMES
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:LPN , CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4286 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-6122
Mailing Address - Country:US
Mailing Address - Phone:912-663-0733
Mailing Address - Fax:912-303-9893
Practice Address - Street 1:9390 FORD AVE STE 8
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-6420
Practice Address - Country:US
Practice Address - Phone:912-756-4713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN059437164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse