Provider Demographics
NPI:1386746469
Name:SMITH, KELLY (DC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:905 NE PRIMA VISTA BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2359
Mailing Address - Country:US
Mailing Address - Phone:772-336-8600
Mailing Address - Fax:772-336-0163
Practice Address - Street 1:905 NE PRIMA VISTA BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2359
Practice Address - Country:US
Practice Address - Phone:772-336-8600
Practice Address - Fax:772-336-0163
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
55421Medicare ID - Type Unspecified