Healthcare Provider Details

I. General information

NPI: 1497925069
Provider Name (Legal Business Name): SPLITROCK CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S SPLITROCK BLVD #1
BRANDON SD
57005-1679
US

IV. Provider business mailing address

314 S SPLITROCK BLVD #1
BRANDON SD
57005-1679
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-8825
  • Fax: 605-582-8827
Mailing address:
  • Phone: 605-582-8825
  • Fax: 605-582-8827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number1031
License Number StateSD

VIII. Authorized Official

Name: DR. BEN AXEL SIMONSON
Title or Position: PRESIDENT
Credential: DC
Phone: 605-582-8825