Healthcare Provider Details

I. General information

NPI: 1316384407
Provider Name (Legal Business Name): ZACHARY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 CLOUDLAND CANYON ST
LAS VEGAS NV
89129-6459
US

IV. Provider business mailing address

3717 CLOUDLAND CANYON ST
LAS VEGAS NV
89129-6459
US

V. Phone/Fax

Practice location:
  • Phone: 702-250-1976
  • Fax:
Mailing address:
  • Phone: 702-250-1976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: