Provider Demographics
NPI:1003999541
Name:SMITH, STEPHEN CARROLL (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CARROLL
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 1:15651 E IMPERIAL HWY
Mailing Address - Street 2:#100
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1600
Mailing Address - Country:US
Mailing Address - Phone:562-902-0050
Mailing Address - Fax:562-902-8677
Practice Address - Street 1:15651 E IMPERIAL HWY
Practice Address - Street 2:#100
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1600
Practice Address - Country:US
Practice Address - Phone:562-902-0050
Practice Address - Fax:562-902-8677
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU16899Medicare UPIN
CADC15394Medicare ID - Type Unspecified