Provider Demographics
NPI:1184214322
Name:SMITH, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11186 BELLAIRE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3062
Mailing Address - Country:US
Mailing Address - Phone:831-227-9377
Mailing Address - Fax:
Practice Address - Street 1:11186 BELLAIRE ST APT 2
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3062
Practice Address - Country:US
Practice Address - Phone:831-227-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic