Provider Demographics
NPI:1043865462
Name:SMITH, VERNON (LAC)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 BALSAM WAY
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2388
Mailing Address - Country:US
Mailing Address - Phone:512-364-8165
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-553-6573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXACO1578171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist