Provider Demographics
NPI:1962544726
Name:SMITH, TERRY GLEN (DC)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:GLEN
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 1:379 AVENUE OF THE CITIES
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4023
Mailing Address - Country:US
Mailing Address - Phone:309-752-1410
Mailing Address - Fax:
Practice Address - Street 1:379 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4023
Practice Address - Country:US
Practice Address - Phone:309-752-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU82386Medicare UPIN