Healthcare Provider Details

I. General information

NPI: 1093859241
Provider Name (Legal Business Name): SMITH CHIROPRACTIC AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W177N9856 RIVERCREST DR SUITE 102
GERMANTOWN WI
53022-4647
US

IV. Provider business mailing address

W177N9856 RIVERCREST DR SUITE 102
GERMANTOWN WI
53022-4647
US

V. Phone/Fax

Practice location:
  • Phone: 262-251-9300
  • Fax: 262-251-9303
Mailing address:
  • Phone: 262-251-9300
  • Fax: 262-251-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2664
License Number StateWI

VIII. Authorized Official

Name: DR. THOMAS PAUL SMITH
Title or Position: OWNER
Credential: D.C.
Phone: 262-251-9300