Healthcare Provider Details

I. General information

NPI: 1801014022
Provider Name (Legal Business Name): SAMMIE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6732 BRYNHURST AVE APT. 2
LOS ANGELES CA
90043-4639
US

IV. Provider business mailing address

6732 BRYNHURST AVE APT. 2
LOS ANGELES CA
90043-4639
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-3939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: