Provider Demographics
NPI:1558367524
Name:SMITH, STACEY CATHLEEN (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:CATHLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 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:810-982-0730
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:810-982-0730
Practice Address - Fax:810-982-0148
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV03654Medicare UPIN
MI0P09990Medicare PIN