Provider Demographics
NPI:1417214545
Name:FRED L. SMITH DCPC
Entity Type:Organization
Organization Name:FRED L. SMITH DCPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-382-4834
Mailing Address - Street 1:908 OAK ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1340
Mailing Address - Country:US
Mailing Address - Phone:618-382-4834
Mailing Address - Fax:618-382-7129
Practice Address - Street 1:908 OAK ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1340
Practice Address - Country:US
Practice Address - Phone:618-382-4834
Practice Address - Fax:618-382-7129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003396Medicaid
ILT36139Medicare UPIN
IL038003396Medicaid