Healthcare Provider Details

I. General information

NPI: 1558558627
Provider Name (Legal Business Name): ROBERT L SMITH DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E CENTER ST
PANGUITCH UT
84759
US

IV. Provider business mailing address

PO BOX 739
PANGUITCH UT
84759-0739
US

V. Phone/Fax

Practice location:
  • Phone: 435-676-8966
  • Fax: 435-676-8966
Mailing address:
  • Phone: 435-676-8966
  • Fax: 435-676-8966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number4927914-1202
License Number StateUT

VIII. Authorized Official

Name: DR. ROBERT L SMITH
Title or Position: PRESIDENT
Credential: DC
Phone: 435-676-8966