Provider Demographics
NPI:1982705976
Name:SMITH, KENNETH PAUL (DC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PAUL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 LIMONITE AVE SUITE L
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509
Mailing Address - Country:US
Mailing Address - Phone:951-685-5345
Mailing Address - Fax:951-685-5393
Practice Address - Street 1:7900 LIMONITE AVE SUITE L
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509
Practice Address - Country:US
Practice Address - Phone:951-685-5345
Practice Address - Fax:951-685-5393
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC018200DMedicare ID - Type Unspecified