=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710190723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMITH CHIROPRACTIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 B AVE STE 303
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-435-4175
-----------------------------------------------------
Fax | 619-435-2995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 B AVE STE 303
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-435-4175
-----------------------------------------------------
Fax | 619-435-2995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARILYN P SMITH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 619-435-4175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | COR690
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------