Provider Demographics
NPI:1487672689
Name:SMITH, BRIAN C (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:SMITH
Suffix:
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 1:703 MILL CREEK RD STE C
Mailing Address - Street 2:PO BOX 1051
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3828
Mailing Address - Country:US
Mailing Address - Phone:609-597-3111
Mailing Address - Fax:609-597-5112
Practice Address - Street 1:703 MILL CREEK RD STE C
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3828
Practice Address - Country:US
Practice Address - Phone:609-597-3111
Practice Address - Fax:609-597-5112
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00410700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ000732OtherPTAN
NJU42503Medicare UPIN