Healthcare Provider Details

I. General information

NPI: 1982969457
Provider Name (Legal Business Name): KEVIN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 SOUTH 600 EAST
PRICE UT
84501-3102
US

IV. Provider business mailing address

PO BOX 867
PRICE UT
84501-0867
US

V. Phone/Fax

Practice location:
  • Phone: 435-637-4246
  • Fax: 435-637-6465
Mailing address:
  • Phone: 435-637-7200
  • Fax: 435-637-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: