Provider Demographics
NPI:1609622448
Name:SMITH, EDDIE CHARLES (HOME HEALTH PROVIDER)
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:HOME HEALTH PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21005 HIGHWAY 365 S
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-8964
Mailing Address - Country:US
Mailing Address - Phone:501-772-7824
Mailing Address - Fax:
Practice Address - Street 1:21005 HIGHWAY 365 S
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-8964
Practice Address - Country:US
Practice Address - Phone:501-765-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 177F00000X, 183700000X, 374U00000X, 251E00000X, 3104A0625X, 132700000X, 146D00000X, 171000000X, 171400000X, 171M00000X, 174200000X
AR904810414172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No175T00000XOther Service ProvidersPeer Specialist
No177F00000XOther Service ProvidersLodging
No183700000XPharmacy Service ProvidersPharmacy Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No171000000XOther Service ProvidersMilitary Health Care Provider
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No174200000XOther Service ProvidersMeals