MEDICARE: SMALLIE CHIROPRACTIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC11659	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ33842Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA
2	GDC000630	OTHER	CA	MEDI-CAL GROUP #

General Provider Information

NPI Number	:	1356475206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALLIE CHIROPRACTIC INC.

Provider Business Mailing Address
First Line	:	2027 GRAND CANAL BLVD STE 21
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6650
Country	:	US
Telephone Number	:	209-957-9601
Fax Number	:

Provider Business Practice Location Address
First Line	:	2027 GRAND CANAL BLVD STE 21
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6650
Country	:	US
Telephone Number	:	209-957-9601
Fax Number	:

Authorized Official
Title or Position	:	OWNER CHIROPRACTOR
Name	:	DON DAVID SMALLIE
Credential	:	DC
Telephone Number	:	209-957-9601

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	02/05/2013

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