Provider Demographics
NPI:1952834194
Name:SMITH, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SMITH
Suffix:
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:PO BOX 12291
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-0291
Mailing Address - Country:US
Mailing Address - Phone:971-208-0287
Mailing Address - Fax:
Practice Address - Street 1:769 HAWTHORNE AVE NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4623
Practice Address - Country:US
Practice Address - Phone:971-208-0287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist