MEDICARE: JOSEPH 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	163WP0808X	Psychiatric/Mental Health Registered Nurse	95063625	CA

General Provider Information

NPI Number	:	1750816500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH SMITH

Provider Business Mailing Address
First Line	:	4995 MURPHY CANYON RD
Second Line	:	ST 204
City	:	SAN DIEGO
State	:	CA
Zip	:	92123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4995 MURPHY CANYON RD
Second Line	:	ST 204
City	:	SAN DIEGO
State	:	CA
Zip	:	92123
Country	:	US
Telephone Number	:	858-603-6981
Fax Number	:

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

Provider Enumeration Date	:	04/28/2017
Last Update Date	:	04/28/2017

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