Provider Demographics
NPI:1629009808
Name:SMITH, JAMES CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JC
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1103 RUSSELL PKWY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5537
Mailing Address - Country:US
Mailing Address - Phone:478-922-4091
Mailing Address - Fax:
Practice Address - Street 1:1103 RUSSELL PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5537
Practice Address - Country:US
Practice Address - Phone:478-922-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA582315860111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT41809Medicare ID - Type Unspecified
GAT98309Medicare UPIN