Healthcare Provider Details

I. General information

NPI: 1174111454
Provider Name (Legal Business Name): ABBY KISOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST
ARLINGTON SD
57212-2084
US

IV. Provider business mailing address

45884 227TH ST
RUTLAND SD
57057-6400
US

V. Phone/Fax

Practice location:
  • Phone: 605-556-0175
  • Fax:
Mailing address:
  • Phone: 605-270-9397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6072
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: