MEDICARE: BENJAMIN SMITH IV

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
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1649944307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN SMITH IV

Provider Business Mailing Address
First Line	:	4575 DEAN MARTIN DR UNIT 1200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-8205
Country	:	US
Telephone Number	:	310-989-7992
Fax Number	:

Provider Business Practice Location Address
First Line	:	4575 DEAN MARTIN DR UNIT 1200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-8205
Country	:	US
Telephone Number	:	310-989-7992
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2021
Last Update Date	:	08/05/2021

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Directions to “ BENJAMIN SMITH IV ” Practice Location

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