Provider Demographics
NPI:1982610978
Name:SMITH, RYAN JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JEFFREY
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 1:1104 PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2642
Mailing Address - Country:US
Mailing Address - Phone:815-224-4450
Mailing Address - Fax:815-883-9686
Practice Address - Street 1:1104 PEORIA ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2642
Practice Address - Country:US
Practice Address - Phone:815-224-4450
Practice Address - Fax:815-883-9686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor