Provider Demographics
NPI:1366058687
Name:SMALLEY, NASH ELIJAH
Entity type:Individual
Prefix:
First Name:NASH
Middle Name:ELIJAH
Last Name:SMALLEY
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-0099
Mailing Address - Country:US
Mailing Address - Phone:660-679-1433
Mailing Address - Fax:417-546-2730
Practice Address - Street 1:517 COY BLVD
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653-5083
Practice Address - Country:US
Practice Address - Phone:417-546-2411
Practice Address - Fax:417-546-2730
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020031366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020031366OtherLICENSE