Healthcare Provider Details

I. General information

NPI: 1043646102
Provider Name (Legal Business Name): GERNARD SMALLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HUGHES WAY STE 150
LONG BEACH CA
90810-1878
US

IV. Provider business mailing address

1501 HUGHES WAY STE 150
LONG BEACH CA
90810-1878
US

V. Phone/Fax

Practice location:
  • Phone: 310-221-6336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: