Healthcare Provider Details

I. General information

NPI: 1104530278
Provider Name (Legal Business Name): LAWRENCE LAMAR SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WABASH AVE
MENTONE CA
92359-1124
US

IV. Provider business mailing address

10411 BERYL AVE
MENTONE CA
92359-1295
US

V. Phone/Fax

Practice location:
  • Phone: 909-492-4106
  • Fax:
Mailing address:
  • Phone: 909-492-4106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: