Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 369 | LA |
NPI | 1003878745 |
---|---|
Provider Name | Phillip L Smith |
First Address | Gonzales, LA 70737-2202 |
Second Address | Gonzales, LA 70737-2202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2006 |
Last Update Date | 21/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1951781 | (05) | LA |
200062121 | STATE GRP PROVIDER NUMBER (01) | LA |
G6933 | B/C PROVIDER NUMBER (01) | LA |