Provider Demographics
NPI:1841678281
Name:SMITH, JUSTIN (DC, LAT)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 SHASTA DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8088
Mailing Address - Country:US
Mailing Address - Phone:715-808-2713
Mailing Address - Fax:
Practice Address - Street 1:1058 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6056
Practice Address - Country:US
Practice Address - Phone:651-439-6500
Practice Address - Fax:651-439-6501
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6908111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor