Provider Demographics
NPI:1841372323
Name:SMITH, MOSES SARAH (DC)
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:SARAH
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4138
Mailing Address - Country:US
Mailing Address - Phone:952-250-4663
Mailing Address - Fax:612-823-3808
Practice Address - Street 1:707 W 34TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4138
Practice Address - Country:US
Practice Address - Phone:612-824-1829
Practice Address - Fax:612-823-3808
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN954603100Medicaid
MN273P1ACOtherBLUE CROSS BLUE SHIELD
MN350003454Medicare ID - Type Unspecified
MN954603100Medicaid