=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790969079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOM SMITH D C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2007
-----------------------------------------------------
Last Update Date | 12/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3334 N POLK ST
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38834-7223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-286-9950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3334 N POLK ST
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38834-7223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-286-9950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. TOM SMITH
-----------------------------------------------------
Credential | D C
-----------------------------------------------------
Telephone | 662-286-9950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 155
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------