Provider Demographics
NPI:1588484034
Name:SMITH, CAMERON LANAI (PT)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:LANAI
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15644 EASTWIND AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5204
Mailing Address - Country:US
Mailing Address - Phone:909-961-7487
Mailing Address - Fax:
Practice Address - Street 1:2275 S MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5303
Practice Address - Country:US
Practice Address - Phone:951-273-7742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist