Provider Demographics
NPI:1235255514
Name:SMITH, KEN ISAIAH (LAC)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:ISAIAH
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:ROBERT
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3622 LANDAU AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5373
Mailing Address - Country:US
Mailing Address - Phone:360-923-0826
Mailing Address - Fax:
Practice Address - Street 1:3663 COLLEGE ST SE STE F
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2303
Practice Address - Country:US
Practice Address - Phone:360-923-0826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA428171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist