Provider Demographics
NPI:1629047899
Name:SMITH, GARVIN B III (DC)
Entity Type:Individual
Prefix:DR
First Name:GARVIN
Middle Name:B
Last Name:SMITH
Suffix:III
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 1:2526 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5016
Mailing Address - Country:US
Mailing Address - Phone:309-792-7017
Mailing Address - Fax:309-764-9326
Practice Address - Street 1:2526 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5016
Practice Address - Country:US
Practice Address - Phone:309-792-7017
Practice Address - Fax:309-764-9326
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007310111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206549Medicare PIN
ILT92968Medicare UPIN