Healthcare Provider Details

I. General information

NPI: 1992734354
Provider Name (Legal Business Name): WESLEY WARREN SMITH ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31749 LA TIENDA RD
WESTLAKE VILLAGE CA
91362-4010
US

IV. Provider business mailing address

31749 LA TIENDA RD
WESTLAKE VILLAGE CA
91362-4010
US

V. Phone/Fax

Practice location:
  • Phone: 818-575-9241
  • Fax: 818-865-8786
Mailing address:
  • Phone: 818-575-9241
  • Fax: 818-865-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: