Individual
COLLIS SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2080 S E ST, SAN BERNARDINO, CA 92408-2706
(909) 825-8989
Mailing address
11650 CHERRY AVE, FONTANA, CA 92337-2786
(909) 904-9465
Taxonomy
Speciality
Code
Description
License number
State
167G00000X
Licensed Psychiatric Technician
Primary
34214
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1124100383
—
CA
Enumeration date
10/08/2009
Last updated
10/08/2009
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