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General NPI Number Information
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NPI Number | 1790436277
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Entity Type | Individual
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Provider Name | CORAN SMITH
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Gender | Male
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Dates
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Enumeration Date | 01/16/2022
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Last Update Date | 01/16/2022
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Provider Practice Location Address
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Address Line | 517 W 103RD PL
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City | CHICAGO
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State | IL
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Zip | 60628-2407
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Country | US
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Telephone | 773-812-5675
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 S MAIN ST STE 700
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City | KALISPELL
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State | MT
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Zip | 59901-5635
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Country | US
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Telephone | 773-812-5675
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | S53010478239
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License Number State | IL
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