Healthcare Provider Details

I. General information

NPI: 1184959173
Provider Name (Legal Business Name): COLLIS SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST
SAN BERNARDINO CA
92408-2706
US

IV. Provider business mailing address

11650 CHERRY AVE
FONTANA CA
92337-2786
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-8989
  • Fax:
Mailing address:
  • Phone: 909-904-9465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number34214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: