Provider Demographics
NPI:1285630053
Name:SMART, TRACY JON (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JON
Last Name:SMART
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-0208
Mailing Address - Country:US
Mailing Address - Phone:218-732-7261
Mailing Address - Fax:218-732-7261
Practice Address - Street 1:708 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1215
Practice Address - Country:US
Practice Address - Phone:218-732-7261
Practice Address - Fax:218-732-7261
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2466111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2C941SMOtherBLUE CROSS/BLUE SHIELD
MN2C941SMOtherBLUE CROSS/BLUE SHIELD