Provider Demographics
NPI:1619996394
Name:SMITH, STEPHANIE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
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 1:278 CARMEL WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4715
Mailing Address - Country:US
Mailing Address - Phone:636-527-1876
Mailing Address - Fax:636-458-7575
Practice Address - Street 1:16925 MANCHESTER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GROVER
Practice Address - State:MO
Practice Address - Zip Code:63040-1219
Practice Address - Country:US
Practice Address - Phone:636-458-7575
Practice Address - Fax:636-458-7979
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004004400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV00326Medicare UPIN