Healthcare Provider Details

I. General information

NPI: 1780144501
Provider Name (Legal Business Name): TRISTEN DAVID SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58417 TWENTYNINE PALMS HIGHWAY
YUCCA VALLEY CA
92284-7310
US

IV. Provider business mailing address

7511 APACHE TRL
YUCCA VALLEY CA
92284-3283
US

V. Phone/Fax

Practice location:
  • Phone: 760-853-4888
  • Fax:
Mailing address:
  • Phone: 760-464-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-XRYJKD
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: