Provider Demographics
NPI:1033202916
Name:SMITH, LARRY R (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
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 1:235 RICHMOND STREET
Mailing Address - Street 2:POB 593
Mailing Address - City:MT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-0593
Mailing Address - Country:US
Mailing Address - Phone:606-256-0242
Mailing Address - Fax:
Practice Address - Street 1:235 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-0593
Practice Address - Country:US
Practice Address - Phone:606-256-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4003111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85001014Medicaid
KY85001014Medicaid