Healthcare Provider Details

I. General information

NPI: 1700095304
Provider Name (Legal Business Name): VINCENT R SMITH OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 MURPHY CANYON RD
SAN DIEGO CA
92123-4428
US

IV. Provider business mailing address

3840 MURPHY CANYON RD
SAN DIEGO CA
92123-4428
US

V. Phone/Fax

Practice location:
  • Phone: 858-614-3380
  • Fax: 858-614-3353
Mailing address:
  • Phone: 858-614-3380
  • Fax: 858-614-3353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number4578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: