Healthcare Provider Details

I. General information

NPI: 1205970233
Provider Name (Legal Business Name): KEVIN SCOTT SMITH REGISTERED CERTIFICA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. KEVIN SCOTT SMITH

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 W LOCUST STREET
LOMPOC CA
93436-7502
US

IV. Provider business mailing address

1337 W LOCUST AVE
LOMPOC CA
93436-7502
US

V. Phone/Fax

Practice location:
  • Phone: 805-740-9799
  • Fax: 805-740-2799
Mailing address:
  • Phone: 805-740-9799
  • Fax: 805-740-2799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRI-S0511241612
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: