Healthcare Provider Details

I. General information

NPI: 1316664279
Provider Name (Legal Business Name): MRS. NETOSHU DENNIS SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 07/24/2024
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 S STATE ST STE B
SAN JACINTO CA
92583-4922
US

IV. Provider business mailing address

1370 S STATE ST STE B
SAN JACINTO CA
92583-4922
US

V. Phone/Fax

Practice location:
  • Phone: 951-791-3596
  • Fax: 951-791-3397
Mailing address:
  • Phone: 951-791-3596
  • Fax: 951-791-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number1316664279
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: