Healthcare Provider Details

I. General information

NPI: 1235964925
Provider Name (Legal Business Name): KAILAND O SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4306 S GRAND ST
MONROE LA
71202-6322
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-322-9418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number18892
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: