Provider Demographics
NPI:1538763032
Name:SMITH, RENDELL LEE III (RDN)
Entity type:Individual
Prefix:MR
First Name:RENDELL
Middle Name:LEE
Last Name:SMITH
Suffix:III
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4263 AUDUBON OAKS CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-5937
Mailing Address - Country:US
Mailing Address - Phone:334-538-4130
Mailing Address - Fax:
Practice Address - Street 1:502 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5014
Practice Address - Country:US
Practice Address - Phone:334-538-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL86152420OtherCOMMISSION ON DIETETIC REGISTRATION
FL9862OtherFLORIDA DEPARTMENT OF HEALTH