Provider Demographics
NPI:1588648349
Name:SMITH, WESTON ALEXANDER (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:ALEXANDER
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:25150 HANCOCK AVE STE 100
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5988
Practice Address - Country:US
Practice Address - Phone:951-698-7720
Practice Address - Fax:951-698-7451
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26086225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT260860OtherBLUE SHIELD OF CALIFORNIA
CAAQ612ZMedicare PIN