Provider Demographics
NPI:1851379499
Name:SMITH, WILLIAM J (DC, CCST)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S AVE D
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6886
Mailing Address - Country:US
Mailing Address - Phone:575-356-4440
Mailing Address - Fax:575-356-4433
Practice Address - Street 1:1400 S AVE D
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6886
Practice Address - Country:US
Practice Address - Phone:505-356-4440
Practice Address - Fax:505-356-4433
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM1130111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201009423OtherPRESBYTERIAN PROVIDER #
NMK9129Medicaid
NMNM01K995OtherBCBS PROVIDER #
NM350023553OtherRAILROAD MEDICARE PIN
NM201009423OtherPRESBYTERIAN PROVIDER #
NMNM01K995OtherBCBS PROVIDER #