Provider Demographics
NPI:1255874327
Name:SMAC SPORT & SPINE
Entity type:Organization
Organization Name:SMAC SPORT & SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DIMICHELE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:443-359-8126
Mailing Address - Street 1:15851 CAMPFIRE PL
Mailing Address - Street 2:
Mailing Address - City:HUGHESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20637-2706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15851 CAMPFIRE PL
Practice Address - Street 2:
Practice Address - City:HUGHESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20637-2706
Practice Address - Country:US
Practice Address - Phone:443-359-8126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty