Provider Demographics
NPI:1497854392
Name:SMITH, KIP A (PT)
Entity Type:Individual
Prefix:MR
First Name:KIP
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:DR
Other - First Name:KIP
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:115 1ST ST W
Mailing Address - Street 2:# 3
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-1101
Mailing Address - Country:US
Mailing Address - Phone:320-362-7900
Mailing Address - Fax:320-362-7904
Practice Address - Street 1:115 1ST ST W
Practice Address - Street 2:# 3
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1101
Practice Address - Country:US
Practice Address - Phone:320-362-7900
Practice Address - Fax:320-362-7904
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9466225100000X
MN6543111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN170123100Medicaid
MN1306173950Medicaid