=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851379499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM J. SMITH DC., CCST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 07/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 S AVE D
-----------------------------------------------------
City | PORTALES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88130-6886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-356-4440
-----------------------------------------------------
Fax | 505-356-4433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 S AVE D
-----------------------------------------------------
City | PORTALES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88130-6886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-356-4440
-----------------------------------------------------
Fax | 575-356-4433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | NM1130
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------