Healthcare Provider Details

I. General information

NPI: 1881038537
Provider Name (Legal Business Name): ALAN R SMITH DC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 E MAIN ST
REXBURG ID
83440-1959
US

IV. Provider business mailing address

57 E MAIN ST
REXBURG ID
83440-1959
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-2313
  • Fax: 208-359-2313
Mailing address:
  • Phone: 208-359-2313
  • Fax: 208-359-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-681
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN SMITH
Title or Position: OWNER
Credential: D.C. P.A.
Phone: 208-359-2313