MEDICARE: DR. KELLY DENISE SMITH D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	6216	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8H3860	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1023082724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY DENISE SMITH D.C.

Provider Business Mailing Address
First Line	:	4709 STATE HIGHWAY 121
Second Line	:	SUITE 124
City	:	THE COLONY
State	:	TX
Zip	:	75056-2914
Country	:	US
Telephone Number	:	972-625-4800
Fax Number	:	972-625-5028

Provider Business Practice Location Address
First Line	:	4709 STATE HIGHWAY 121
Second Line	:	SUITE 124
City	:	THE COLONY
State	:	TX
Zip	:	75056-2914
Country	:	US
Telephone Number	:	972-625-4800
Fax Number	:	972-625-5028

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	11/04/2016

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