Provider Demographics
NPI:1922001502
Name:SMITH, LARRY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LEE
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 1:220 N BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6717
Mailing Address - Country:US
Mailing Address - Phone:321-327-7014
Mailing Address - Fax:321-821-1924
Practice Address - Street 1:100 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4303
Practice Address - Country:US
Practice Address - Phone:321-327-7014
Practice Address - Fax:321-821-1924
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7178111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5804715OtherGHI
P1659960OtherOXFORD
FL55485OtherBLUE CROSS BLUE SHIELD
FL665421OtherACN
FL381082800Medicaid
FLU64127Medicare UPIN
FL55485Medicare ID - Type Unspecified