Provider Demographics
NPI:1871352104
Name:SMITH, CALEB MITCHELL
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:MITCHELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 HOLMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7837
Mailing Address - Country:US
Mailing Address - Phone:843-652-8440
Mailing Address - Fax:
Practice Address - Street 1:4320 HOLMESTOWN RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7837
Practice Address - Country:US
Practice Address - Phone:843-652-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program