1679502926 NPI number — MR. JARED W SMITH PAC

Table of content: MR. JARED W SMITH PAC (NPI 1679502926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679502926 NPI number — MR. JARED W SMITH PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JARED
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679502926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
647 W EAST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95926-7201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-343-4757
Provider Business Mailing Address Fax Number:
530-343-3347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1158 N COURT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-0436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-343-4757
Provider Business Practice Location Address Fax Number:
530-343-3347
Provider Enumeration Date:
06/30/2006

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: 363A00000X , with the licence number:  PA17095 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA17095 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00126903 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".