Provider Demographics
NPI:1003878745
Name:SMITH, PHILLIP L (DC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
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 1:12320 HIGHWAY 44 STE A
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2202
Mailing Address - Country:US
Mailing Address - Phone:225-644-8671
Mailing Address - Fax:225-644-6427
Practice Address - Street 1:12320 HIGHWAY 44 STE A
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2202
Practice Address - Country:US
Practice Address - Phone:225-644-8671
Practice Address - Fax:225-644-6427
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1951781Medicaid
LA200062121OtherSTATE GRP PROVIDER NUMBER
LAG6933OtherB/C PROVIDER NUMBER
LA1951781Medicaid