Healthcare Provider Details

I. General information

NPI: 1306698188
Provider Name (Legal Business Name): DAVID SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4726 SANTA MONICA AVE
SAN DIEGO CA
92107-2209
US

IV. Provider business mailing address

5439 MOUNTAIN VISTA DR
SAN ANTONIO TX
78247-4640
US

V. Phone/Fax

Practice location:
  • Phone: 737-802-5103
  • Fax:
Mailing address:
  • Phone: 173-780-2510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number85271
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: