Provider Demographics
NPI:1144249707
Name:SMITH, TONY LEE (DC, QME)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42135 10TH ST W
Mailing Address - Street 2:STE 101
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7099
Mailing Address - Country:US
Mailing Address - Phone:661-949-6649
Mailing Address - Fax:661-949-9431
Practice Address - Street 1:936 W AVENUE J4
Practice Address - Street 2:#104
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4246
Practice Address - Country:US
Practice Address - Phone:661-949-6649
Practice Address - Fax:661-949-9431
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 22860111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA045412Medicare ID - Type Unspecified