Healthcare Provider Details

I. General information

NPI: 1063292803
Provider Name (Legal Business Name): CRYSTAL DAWN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 K ST
CRESCENT CITY CA
95531-4107
US

IV. Provider business mailing address

400 L ST
CRESCENT CITY CA
95531-4114
US

V. Phone/Fax

Practice location:
  • Phone: 707-464-3191
  • Fax: 707-464-7169
Mailing address:
  • Phone: 707-464-3191
  • Fax: 707-464-7169

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: