=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457661399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY A. SMITH, D.C. A PROFESSIONAL CHIROPRACTIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2010
-----------------------------------------------------
Last Update Date | 10/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 I ST
-----------------------------------------------------
City | LOS BANOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93635-4313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-826-5865
-----------------------------------------------------
Fax | 209-826-1571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 I ST
-----------------------------------------------------
City | LOS BANOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93635-4313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-826-5865
-----------------------------------------------------
Fax | 209-826-1571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GREGORY ALLEN SMITH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 209-826-5865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 12059
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------