Provider Demographics
NPI:1730302647
Name:RECER, SHELLY MARIE SMITH (DC)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:MARIE SMITH
Last Name:RECER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MARIE SMITH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:3440 FEDERAL DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3501
Mailing Address - Country:US
Mailing Address - Phone:651-405-3990
Mailing Address - Fax:651-403-5643
Practice Address - Street 1:3440 FEDERAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3501
Practice Address - Country:US
Practice Address - Phone:651-405-3990
Practice Address - Fax:651-403-5643
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003434111N00000X
MN3434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN442415000Medicaid
MN716342800Medicaid
MN10G29SMOtherBCBS
MN716342800Medicaid
MN350001926Medicare ID - Type Unspecified