Provider Demographics
NPI:1306954482
Name:SMITH, PATRICK R (DC)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301
Mailing Address - Country:US
Mailing Address - Phone:815-223-0647
Mailing Address - Fax:815-223-0987
Practice Address - Street 1:130 3RD ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301
Practice Address - Country:US
Practice Address - Phone:815-223-0647
Practice Address - Fax:815-223-0987
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38010345111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15633Medicare ID - Type Unspecified