Provider Demographics
NPI:1427192707
Name:SMITH, CHARLES BURRELL JR (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BURRELL
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 1:507 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-3533
Mailing Address - Country:US
Mailing Address - Phone:479-229-0332
Mailing Address - Fax:479-229-0465
Practice Address - Street 1:507 N 2ND ST
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-3533
Practice Address - Country:US
Practice Address - Phone:479-229-0332
Practice Address - Fax:479-229-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y299OtherBLUE CROSS BLUE SHIELD
AR040325OtherUNITED HEALTH CARE
AR7017685OtherAETNA
AR500114OtherNOVASYS
AR5Y299Medicare ID - Type Unspecified
ARV05437Medicare UPIN