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General NPI Number Information
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NPI Number | 1003005513
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Entity Type | Organization
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Legal Business Name | KELLY SMITH
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Dates
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Enumeration Date | 10/20/2007
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Last Update Date | 04/04/2012
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Provider Practice Location Address
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Address Line | 30724 BENTON RD C-302 #551
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City | WINCHESTER
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State | CA
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Zip | 92596-8470
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Country | US
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Telephone | 951-837-4703
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Fax | 951-837-4702
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Provider Business Mailing Address
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Address Line | 29970 TECHNOLOGY DR #208
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City | MURRIETA
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State | CA
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Zip | 92563-2645
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Country | US
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Telephone | 951-837-4703
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Fax | 951-837-4702
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Authorized Official
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Title or Position | NURSE
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Name | KELLY SMITH
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Credential | L.V.N.
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Telephone | 951-837-4703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 187389
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License Number State | CA
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