Provider Demographics
NPI:1699539445
Name:SMITH, DEVONE
Entity type:Individual
Prefix:
First Name:DEVONE
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 1:66 S SAN GORGONIO AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6020
Mailing Address - Country:US
Mailing Address - Phone:951-922-0111
Mailing Address - Fax:
Practice Address - Street 1:66 S SAN GORGONIO AVE STE 6
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6020
Practice Address - Country:US
Practice Address - Phone:951-922-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker