Provider Demographics
NPI:1558907865
Name:SMITH, BRIAN JOSEPH JR (ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 BLANCHARD PL
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4023
Mailing Address - Country:US
Mailing Address - Phone:909-935-5270
Mailing Address - Fax:
Practice Address - Street 1:4921 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-1035
Practice Address - Country:US
Practice Address - Phone:909-935-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer