Provider Demographics
NPI:1861899692
Name:SMITH, ERIK JOHN
Entity type:Individual
Prefix:MR
First Name:ERIK
Middle Name:JOHN
Last Name:SMITH
Suffix:
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 1:321 W JEFFERSON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1024
Mailing Address - Country:US
Mailing Address - Phone:815-262-5614
Mailing Address - Fax:
Practice Address - Street 1:321 W JEFFERSON ST
Practice Address - Street 2:APT #2
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1024
Practice Address - Country:US
Practice Address - Phone:815-262-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer