Provider Demographics
NPI:1467595470
Name:SMITH, COLLIN P
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 BEAUMONT CENTRE CIR STE 130
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1966
Mailing Address - Country:US
Mailing Address - Phone:859-219-1014
Mailing Address - Fax:
Practice Address - Street 1:3165 BEAUMONT CENTRE CIR STE 130
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1966
Practice Address - Country:US
Practice Address - Phone:859-219-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2496756111N00000X
KY5040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11696849OtherCAQH NO.