=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558907865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN JOSEPH SMITH JR. ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2019
-----------------------------------------------------
Last Update Date | 11/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4921 CEDAR AVE
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-935-5270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 633 BLANCHARD PL
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91711-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-935-5270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------