Healthcare Provider Details

I. General information

NPI: 1699006940
Provider Name (Legal Business Name): SMART HEALTH & WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 S PROSPECT RD SUITE D
BLOOMINGTON IL
61704-4581
US

IV. Provider business mailing address

409 S PROSPECT RD SUITE D
BLOOMINGTON IL
61704-4581
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-8325
  • Fax:
Mailing address:
  • Phone: 309-661-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038011302
License Number StateIL

VIII. Authorized Official

Name: DR. GREGORY W SMART
Title or Position: OWNER
Credential: D.C.
Phone: 309-661-8325