Provider Demographics
NPI:1114175122
Name:DR. GARY W. SMART
Entity Type:Organization
Organization Name:DR. GARY W. SMART
Other - Org Name:SOUTH PORTLAND CHIROPRACTIC & MASSAGE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-774-7242
Mailing Address - Street 1:597 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5412
Mailing Address - Country:US
Mailing Address - Phone:207-774-7242
Mailing Address - Fax:
Practice Address - Street 1:597 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5412
Practice Address - Country:US
Practice Address - Phone:207-774-7242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR594261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESM-015-257Medicare UPIN