Provider Demographics
NPI:1588944359
Name:SMITH CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:SMITH CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DICCP
Authorized Official - Phone:715-833-3505
Mailing Address - Street 1:829 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6102
Mailing Address - Country:US
Mailing Address - Phone:715-833-3505
Mailing Address - Fax:715-833-8515
Practice Address - Street 1:829 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6102
Practice Address - Country:US
Practice Address - Phone:715-833-3505
Practice Address - Fax:715-833-8515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3693-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38960000Medicaid
WI000035279Medicare PIN
WI38960000Medicaid