Provider Demographics
NPI:1407525462
Name:SMITH, KEVIN M (RN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W. SAN BERNARDINO RD.
Mailing Address - Street 2:ATTN. MENTAL HEALTH UNIT
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-331-7331
Mailing Address - Fax:626-859-5854
Practice Address - Street 1:210 W. SAN BERNARDINO RD.
Practice Address - Street 2:ATTN. MENTAL HEALTH UNIT
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-331-7331
Practice Address - Fax:626-859-5854
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95128556163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult