Provider Demographics
NPI:1790442291
Name:SMITH, EDDIE LEE JR
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:LEE
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W FLORIDA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4628
Mailing Address - Country:US
Mailing Address - Phone:951-658-7122
Mailing Address - Fax:951-658-7140
Practice Address - Street 1:1300 W FLORIDA AVE STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4628
Practice Address - Country:US
Practice Address - Phone:951-658-7122
Practice Address - Fax:951-658-7140
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator