Basic Information
Provider Information
NPI: 1003142274
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: ROSCOE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4702 W COMMERCIAL DR
Address2: SUITE C
City: NORTH LITTLE ROCK
State: AR
PostalCode: 721167068
CountryCode: US
TelephoneNumber: 5018125545
FaxNumber:  
Practice Location
Address1: 4702 W COMMERCIAL DR
Address2: SUITE C
City: NORTH LITTLE ROCK
State: AR
PostalCode: 721167068
CountryCode: US
TelephoneNumber: 5018125545
FaxNumber: 5018125546
Other Information
ProviderEnumerationDate: 10/23/2009
LastUpdateDate: 10/23/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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