Provider Demographics
NPI:1396542460
Name:SMITH, KENNETH ADRAIN (LMT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ADRAIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 N 4TH ST # B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1104 N 4TH ST # B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3217
Practice Address - Country:US
Practice Address - Phone:208-292-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4015225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist