Healthcare Provider Details

I. General information

NPI: 1619361086
Provider Name (Legal Business Name): MS. TAMIEKA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E MAIN ST STE 117
BARSTOW CA
92311-2361
US

IV. Provider business mailing address

15095 AMARGOSA RD STE 208
VICTORVILLE CA
92394-1879
US

V. Phone/Fax

Practice location:
  • Phone: 760-255-1496
  • Fax: 760-513-4675
Mailing address:
  • Phone: 760-245-4695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: