Healthcare Provider Details

I. General information

NPI: 1023591070
Provider Name (Legal Business Name): PETER CORNELIUS SMITH RCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13651 WILLARD ST
PANORAMA CITY CA
91402
US

IV. Provider business mailing address

PO BOX 16843
ENCINO CA
91416-6843
US

V. Phone/Fax

Practice location:
  • Phone: 818-375-2822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P3900X
TaxonomyNeonatal/Pediatric Registered Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: