Provider Demographics
NPI:1417743451
Name:SMITH, LARISSA ROSE (DC)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13136 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-4114
Mailing Address - Country:US
Mailing Address - Phone:308-858-2055
Mailing Address - Fax:530-885-0303
Practice Address - Street 1:13136 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-4114
Practice Address - Country:US
Practice Address - Phone:308-858-2055
Practice Address - Fax:530-885-0303
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor