MEDICARE: MR. SEAN ARTHUR SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	689343	CA

General Provider Information

NPI Number	:	1477184919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SEAN ARTHUR SMITH

Provider Business Mailing Address
First Line	:	11962 WOODSIDE AVE
Second Line	:
City	:	LAKESIDE
State	:	CA
Zip	:	92040-2914
Country	:	US
Telephone Number	:	619-561-1222
Fax Number	:	619-390-8663

Provider Business Practice Location Address
First Line	:	11962 WOODSIDE AVE
Second Line	:
City	:	LAKESIDE
State	:	CA
Zip	:	92040-2914
Country	:	US
Telephone Number	:	619-561-1222
Fax Number	:	619-390-9487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2020
Last Update Date	:	01/05/2023

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Directions to “ MR. SEAN ARTHUR SMITH ” Practice Location

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