=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497766562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY SMALLWOOD D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 WHITEHORSE PIKE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-652-3336
-----------------------------------------------------
Fax | 609-652-3336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 529
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240-0529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-652-3336
-----------------------------------------------------
Fax | 609-652-3336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00366700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------