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NPI Code Detail

MEDICARE: TIARA DIANE SMITH

MEDICARE: TIARA DIANE SMITH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171W00000XContractorIL

General Provider Information

NPI Number : 1093647067
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIARA DIANE SMITH
Provider Business Mailing Address
First Line : 22420 BROOKWOOD DR
Second Line :
City : SAUK VILLAGE
State : IL
Zip : 60411-5810
Country : US
Telephone Number : 464-249-4102
Fax Number :
Provider Business Practice Location Address
First Line : 1440 W TAYLOR ST # 236
Second Line :
City : CHICAGO
State : IL
Zip : 60607-4623
Country : US
Telephone Number : 464-249-4102
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/02/2026
Last Update Date : 06/02/2026

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Directions to “ TIARA DIANE SMITH ” Practice Location

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