Provider Demographics
NPI:1497103758
Name:SMITH, TIMOTHY (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81337 AVENIDA ROMERO
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201
Mailing Address - Country:US
Mailing Address - Phone:760-485-7656
Mailing Address - Fax:
Practice Address - Street 1:81337 AVENIDA ROMERO
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201
Practice Address - Country:US
Practice Address - Phone:760-485-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14812171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor