1700115870 NPI number — DR MOSES S M SMITH CHIROPRACTIC LLC

Table of content: (NPI 1700115870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700115870 NPI number — DR MOSES S M SMITH CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR MOSES S M SMITH CHIROPRACTIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOE BODYWORKS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700115870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 W 34TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55408-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-824-1829
Provider Business Mailing Address Fax Number:
612-823-3808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 W 34TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-4138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-824-1829
Provider Business Practice Location Address Fax Number:
612-823-3808
Provider Enumeration Date:
12/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MOSES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
612-824-1829

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4728 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 954603100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273P1AC . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 350003454 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CC0938A . This is a "CHIROCARE LANDMARK" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".