Provider Demographics
NPI:1699770487
Name:SMITH, VENUS CRYSTAL (DC)
Entity type:Individual
Prefix:
First Name:VENUS
Middle Name:CRYSTAL
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 1894
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-1894
Mailing Address - Country:US
Mailing Address - Phone:541-347-5169
Mailing Address - Fax:
Practice Address - Street 1:780 2NDSTREET SE STE 6
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-1894
Practice Address - Country:US
Practice Address - Phone:541-347-5169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-5608631OtherEIN
ORU68252Medicare UPIN
ORR100897Medicare ID - Type Unspecified