Provider Demographics
NPI:1508840489
Name:SMITH, GREGORY KENT (PT, MOMT, OCS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KENT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, MOMT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29645 RANCHO CALIFORNIA RD
Mailing Address - Street 2:STE. 234
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6200
Mailing Address - Country:US
Mailing Address - Phone:951-506-3001
Mailing Address - Fax:951-506-3002
Practice Address - Street 1:31515 RANCHO PUEBLO RD
Practice Address - Street 2:STE. 101
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4836
Practice Address - Country:US
Practice Address - Phone:951-303-1414
Practice Address - Fax:951-303-1616
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0175124OtherWA DEPT OF LABOR
CACB233269Medicare PIN
CACA102743Medicare PIN
CACA152232Medicare PIN