Healthcare Provider Details

I. General information

NPI: 1285630053
Provider Name (Legal Business Name): TRACY JON SMART DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 BRIDGE ST
PARK RAPIDS MN
56470-1215
US

IV. Provider business mailing address

PO BOX 208
PARK RAPIDS MN
56470-0208
US

V. Phone/Fax

Practice location:
  • Phone: 218-732-7261
  • Fax: 218-732-7261
Mailing address:
  • Phone: 218-732-7261
  • Fax: 218-732-7261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2466
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: