Healthcare Provider Details

I. General information

NPI: 1902387293
Provider Name (Legal Business Name): CHADWYCKE RICHARD SMITH NP, AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SAN PABLO ST STE 3800
LOS ANGELES CA
90033-5328
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5720
  • Fax:
Mailing address:
  • Phone: 323-442-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95009361
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number841328
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number841328
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: