Provider Demographics
NPI:1790529923
Name:SMITH, KEVIN ETWOOD JR
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ETWOOD
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 1:1390 E JASPER DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4347
Mailing Address - Country:US
Mailing Address - Phone:480-862-3648
Mailing Address - Fax:
Practice Address - Street 1:1390 E JASPER DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4347
Practice Address - Country:US
Practice Address - Phone:480-862-3648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251S00000X, 261QA0600X, 261QD1600X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities