Healthcare Provider Details

I. General information

NPI: 1689779647
Provider Name (Legal Business Name): JOHN A SMITH, DC, CCSP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2926 CAPITAL BLVD
RALEIGH NC
27604-3235
US

IV. Provider business mailing address

2926 CAPITAL BLVD
RALEIGH NC
27604-3235
US

V. Phone/Fax

Practice location:
  • Phone: 919-878-8848
  • Fax: 919-878-8863
Mailing address:
  • Phone: 919-878-8848
  • Fax: 919-878-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1412
License Number StateNC

VIII. Authorized Official

Name: DR. JOHN A. SMITH
Title or Position: OWNER
Credential: DC
Phone: 919-878-8848