Provider Demographics
NPI:1871784249
Name:SMITH, RALPH III (LCDC)
Entity type:Individual
Prefix:MR
First Name:RALPH
Middle Name:
Last Name:SMITH
Suffix:III
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 N LOOP 1604 W
Mailing Address - Street 2:APT 124
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2595
Mailing Address - Country:US
Mailing Address - Phone:210-292-7722
Mailing Address - Fax:210-292-2520
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:59 MHS SGOW STE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-7722
Practice Address - Fax:210-292-2520
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9305247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other