=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558391169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON LARRY SMITH DC, MS, DACNB
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 MEDICAL DR STE 200
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-8928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-292-4400
-----------------------------------------------------
Fax | 844-308-6615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 MEDICAL DR STE 200
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-8928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-292-4400
-----------------------------------------------------
Fax | 844-308-6615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 369867-1202
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------