Provider Demographics
NPI:1104530278
Name:SMITH, LAWRENCE LAMAR
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:LAMAR
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 1:10411 BERYL AVE
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-1295
Mailing Address - Country:US
Mailing Address - Phone:909-492-4106
Mailing Address - Fax:
Practice Address - Street 1:1350 WABASH AVE
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-1124
Practice Address - Country:US
Practice Address - Phone:909-492-4106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5727225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant