1235255514 NPI number — MR. KEN ISAIAH SMITH L.AC.

Table of content: MR. KEN ISAIAH SMITH L.AC. (NPI 1235255514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235255514 NPI number — MR. KEN ISAIAH SMITH L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KEN
Provider Middle Name:
ISAIAH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
KENNETH
Provider Other Middle Name:
ROBERT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235255514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3622 LANDAU AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-5373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-923-0826
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3663 COLLEGE ST SE STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-923-0826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  428 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)