Provider Demographics
NPI:1194696286
Name:SMITH, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
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 1:494 S MACY ST SPC 89
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-0110
Mailing Address - Country:US
Mailing Address - Phone:909-434-6317
Mailing Address - Fax:
Practice Address - Street 1:494 S MACY ST SPC 89
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-0110
Practice Address - Country:US
Practice Address - Phone:909-434-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-13
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95328449163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty