Provider Demographics
NPI:1538176599
Name:SMITH, GREGORY LEE (RPH,DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH,DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:KINGS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:96143-0967
Mailing Address - Country:US
Mailing Address - Phone:530-546-8252
Mailing Address - Fax:
Practice Address - Street 1:8611 N LAKE BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGS BEACH
Practice Address - State:CA
Practice Address - Zip Code:96143-0967
Practice Address - Country:US
Practice Address - Phone:530-546-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23375111N00000X
CA35063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU56467Medicare UPIN