Basic Information
| Provider Information | |||||||||
| NPI: | 1154846160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH-SAMPSON | ||||||||
| FirstName: | ROESHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 W PROFESSIONAL PARK CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707779283 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 PROFESSIONAL VILLAGE CIR | ||||||||
| Address2: | |||||||||
| City: | LADYS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299071575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433711602 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2017 | ||||||||
| LastUpdateDate: | 08/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-17-37766 | SC | Y |
No ID Information.