Healthcare Provider Details

I. General information

NPI: 1922001502
Provider Name (Legal Business Name): LARRY LEE SMITH D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W NEW HAVEN AVE
MELBOURNE FL
32901-4303
US

IV. Provider business mailing address

220 N BABCOCK ST
MELBOURNE FL
32935-6717
US

V. Phone/Fax

Practice location:
  • Phone: 321-327-7014
  • Fax: 321-821-1924
Mailing address:
  • Phone: 321-327-7014
  • Fax: 321-821-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH7178
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: