Provider Demographics
NPI:1639372162
Name:SMITH, GARY R (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:74-967 HWY 111
Mailing Address - Street 2:INDIAN WELLS CHIROPRACTIC CLINIC
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210
Mailing Address - Country:US
Mailing Address - Phone:760-346-5255
Mailing Address - Fax:760-346-5028
Practice Address - Street 1:74-967 HWY 111
Practice Address - Street 2:INDIAN WELLS CHIROPRACTIC CLINIC
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210
Practice Address - Country:US
Practice Address - Phone:760-346-5255
Practice Address - Fax:760-346-5028
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0041111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC17960OtherSTATE LIC
CADC17960OtherSTATE LIC