Healthcare Provider Details

I. General information

NPI: 1972522787
Provider Name (Legal Business Name): LISA M SMITH D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date: 11/19/2008
Reactivation Date: 09/22/2022

III. Provider practice location address

10907 EXCELSIOR BLVD
HOPKINS MN
55343-3420
US

IV. Provider business mailing address

10907 EXCELSIOR BLVD
HOPKINS MN
55343-3420
US

V. Phone/Fax

Practice location:
  • Phone: 952-930-3303
  • Fax: 952-930-3304
Mailing address:
  • Phone: 952-930-3303
  • Fax: 952-930-3304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number2637
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: