Basic Information
| Provider Information | |||||||||
| NPI: | 1972522787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10907 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | HOPKINS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553433420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529303303 | ||||||||
| FaxNumber: | 9529303304 | ||||||||
| Practice Location | |||||||||
| Address1: | 10907 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | HOPKINS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553433420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529303303 | ||||||||
| FaxNumber: | 9529303304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/19/2008 | ||||||||
| NPIReactivationDate: | 09/22/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NX0800X | 2637 | MN | Y | Chiropractic Providers | Chiropractor | Orthopedic |
No ID Information.