Healthcare Provider Details

I. General information

NPI: 1366670887
Provider Name (Legal Business Name): SUSAN M. SMITH DC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 SOUTH MORRISON
COLLINSVILLE IL
62234
US

IV. Provider business mailing address

226 SOUTH MORRISON
COLLINSVILLE IL
62234
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-0909
  • Fax: 318-344-0909
Mailing address:
  • Phone: 618-344-0909
  • Fax: 318-344-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038006983
License Number StateIL

VIII. Authorized Official

Name: DR. SUSAN MARIE SMITH
Title or Position: CHIROPRACTIC PHYSICIAN
Credential: DC
Phone: 618-344-0909