Provider Demographics
NPI:1912399494
Name:SMITH, KELLY BRETT (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BRETT
Last Name:SMITH
Suffix:
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 1:2123 S HIGHWAY 92
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-5269
Mailing Address - Country:US
Mailing Address - Phone:520-459-5199
Mailing Address - Fax:
Practice Address - Street 1:2123 S HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-5269
Practice Address - Country:US
Practice Address - Phone:520-459-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor