Provider Demographics
NPI:1528729738
Name:SMITH, CLOTELEOUS RUSH
Entity type:Individual
Prefix:
First Name:CLOTELEOUS
Middle Name:RUSH
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 MIDTOWN PL STE 116
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-1300
Mailing Address - Country:US
Mailing Address - Phone:984-289-8602
Mailing Address - Fax:
Practice Address - Street 1:1631 MIDTOWN PL STE 116
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-1300
Practice Address - Country:US
Practice Address - Phone:984-289-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC6416253Z00000X
172A00000X, 347C00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite Care