Provider Demographics
NPI:1063476000
Name:SMITH, THERESA L (DC)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
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 1:122 E WALNUT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3449
Mailing Address - Country:US
Mailing Address - Phone:626-355-2626
Mailing Address - Fax:
Practice Address - Street 1:122 E WALNUT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3449
Practice Address - Country:US
Practice Address - Phone:626-355-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91242Medicare UPIN