1982781084 NPI number — DR. RICHARD KEANE SMITH PHD CRC

Table of content: DR. RICHARD KEANE SMITH PHD CRC (NPI 1982781084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982781084 NPI number — DR. RICHARD KEANE SMITH PHD CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
RICHARD
Provider Middle Name:
KEANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD CRC
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:
1982781084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6037 EASTWOOD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTA LOMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-240-3217
Provider Business Mailing Address Fax Number:
760-240-3274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9775 MOCKINGBIRD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-240-3217
Provider Business Practice Location Address Fax Number:
760-240-3274
Provider Enumeration Date:
11/01/2006

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: 103TC0700X , with the licence number:  PSY13809 , 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)





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