Provider Demographics
NPI:1457661399
Name:GREGORY A. SMITH, D.C. A PROFESSIONAL CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:GREGORY A. SMITH, D.C. A PROFESSIONAL CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-826-5865
Mailing Address - Street 1:912 I ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4313
Mailing Address - Country:US
Mailing Address - Phone:209-826-5865
Mailing Address - Fax:209-826-1571
Practice Address - Street 1:912 I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4313
Practice Address - Country:US
Practice Address - Phone:209-826-5865
Practice Address - Fax:209-826-1571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0120590Medicare PIN
CAT04605Medicare UPIN