Provider Demographics
NPI:1487899779
Name:SMITH, GLENDA (PRIVATE HEALTH CARE)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PRIVATE HEALTH CARE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JACKIE DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4454
Mailing Address - Country:US
Mailing Address - Phone:770-942-1120
Mailing Address - Fax:770-942-6512
Practice Address - Street 1:4160 JACKIE DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-4454
Practice Address - Country:US
Practice Address - Phone:770-942-1120
Practice Address - Fax:770-942-6512
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048-R-0500251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health