Provider Demographics
NPI:1427599497
Name:STACEY SMITH CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:STACEY SMITH CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:CATHLEEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-491-9547
Mailing Address - Street 1:1009 ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3729
Mailing Address - Country:US
Mailing Address - Phone:586-491-9547
Mailing Address - Fax:810-982-0148
Practice Address - Street 1:1009 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3729
Practice Address - Country:US
Practice Address - Phone:586-491-9547
Practice Address - Fax:810-982-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP09990Medicare PIN
MIV03654Medicare UPIN