Healthcare Provider Details

I. General information

NPI: 1265514632
Provider Name (Legal Business Name): JONATHAN D SMITH DC W/ PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E IDAHO AVE STE 30
LAS CRUCES NM
88005-3242
US

IV. Provider business mailing address

3850 E LOHMAN AVE SUITE 100
LAS CRUCES NM
88011-8288
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-0238
  • Fax:
Mailing address:
  • Phone: 575-521-0793
  • Fax: 575-532-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1961
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: