Healthcare Provider Details

I. General information

NPI: 1548324023
Provider Name (Legal Business Name): ELITE CHIROPRACTIC BROOKINGS PROF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 6TH ST
BROOKINGS SD
57006-1604
US

IV. Provider business mailing address

20456 LAKE RIDGE DR
PRIOR LAKE MN
55372-7805
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-2225
  • Fax: 605-697-5838
Mailing address:
  • Phone: 952-492-5914
  • Fax: 952-492-5913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1095
License Number StateSD

VIII. Authorized Official

Name: DR. BRADLEY DALE WILDBERG
Title or Position: PRESIDENT,OWNER
Credential: D.C.
Phone: 612-910-6600