1730302647 NPI number — MRS. SHELLY MARIE SMITH RECER DC

Table of content: MRS. SHELLY MARIE SMITH RECER DC (NPI 1730302647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730302647 NPI number — MRS. SHELLY MARIE SMITH RECER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RECER
Provider First Name:
SHELLY
Provider Middle Name:
MARIE SMITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
SHELLY
Provider Other Middle Name:
MARIE SMITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730302647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3440 FEDERAL DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-405-3990
Provider Business Mailing Address Fax Number:
651-403-5643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3440 FEDERAL DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-405-3990
Provider Business Practice Location Address Fax Number:
651-403-5643
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  003434 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 3434 , 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: 442415000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 716342800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10G29SM . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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