Provider Demographics
NPI:1760228613
Name:SMITH, MS-CHALAE' (CPT)
Entity type:Individual
Prefix:
First Name:MS-CHALAE'
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 W CHESHIRE ST
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4428
Mailing Address - Country:US
Mailing Address - Phone:909-644-7023
Mailing Address - Fax:
Practice Address - Street 1:473 E. CARNEGIE DR.
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:62408
Practice Address - Country:US
Practice Address - Phone:909-644-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT-00043776246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy