Provider Demographics
NPI:1356647119
Name:SMITH, MICHAEL JOHN JR (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:SMITH
Suffix:JR
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 1:3409 W 12600 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7260
Mailing Address - Country:US
Mailing Address - Phone:801-688-3693
Mailing Address - Fax:
Practice Address - Street 1:3409 W 12600 S
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7260
Practice Address - Country:US
Practice Address - Phone:801-688-3693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7845949-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor