Healthcare Provider Details

I. General information

NPI: 1255874327
Provider Name (Legal Business Name): SMAC SPORT & SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15851 CAMPFIRE PL
HUGHESVILLE MD
20637-2706
US

IV. Provider business mailing address

15851 CAMPFIRE PL
HUGHESVILLE MD
20637-2706
US

V. Phone/Fax

Practice location:
  • Phone: 443-359-8126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. NICHOLAS ROBERT DIMICHELE
Title or Position: OWNER
Credential: D.C.
Phone: 443-359-8126