Provider Demographics
NPI:1003005513
Name:KELLY SMITH
Entity type:Organization
Organization Name:KELLY SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:951-837-4703
Mailing Address - Street 1:29970 TECHNOLOGY DR
Mailing Address - Street 2:#208
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2645
Mailing Address - Country:US
Mailing Address - Phone:951-837-4703
Mailing Address - Fax:951-837-4702
Practice Address - Street 1:30724 BENTON RD
Practice Address - Street 2:C-302 #551
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-8470
Practice Address - Country:US
Practice Address - Phone:951-837-4703
Practice Address - Fax:951-837-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-20
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA187389164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty