Healthcare Provider Details

I. General information

NPI: 1033033014
Provider Name (Legal Business Name): MICHAEL SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 1ST ST
SAN RAFAEL CA
94901-3739
US

IV. Provider business mailing address

680 JUNCTION AVE APT 204
LIVERMORE CA
94551-4390
US

V. Phone/Fax

Practice location:
  • Phone: 925-723-3390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: