Healthcare Provider Details

I. General information

NPI: 1861511479
Provider Name (Legal Business Name): CHIROSPORT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E HOLLY BLVD
BRANDON SD
57005-1114
US

IV. Provider business mailing address

128 E HOLLY BLVD
BRANDON SD
57005-1114
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-8800
  • Fax:
Mailing address:
  • Phone: 605-582-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1019
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberC1019
License Number StateSD

VIII. Authorized Official

Name: PAIGE M HONNER
Title or Position: CLINIC MANAGER
Credential:
Phone: 605-201-9191