Healthcare Provider Details

I. General information

NPI: 1477184919
Provider Name (Legal Business Name): MR. SEAN ARTHUR SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 01/05/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11962 WOODSIDE AVE
LAKESIDE CA
92040-2914
US

IV. Provider business mailing address

11962 WOODSIDE AVE
LAKESIDE CA
92040-2914
US

V. Phone/Fax

Practice location:
  • Phone: 619-561-1222
  • Fax: 619-390-9487
Mailing address:
  • Phone: 619-561-1222
  • Fax: 619-390-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number689343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: