Healthcare Provider Details

I. General information

NPI: 1184490344
Provider Name (Legal Business Name): KRAVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 22ND AVE S
BROOKINGS SD
57006-2803
US

IV. Provider business mailing address

1040 22ND AVE S
BROOKINGS SD
57006-2803
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-5728
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: BROOK WILDERSON
Title or Position: MASSAGE THERAPIST
Credential:
Phone: 402-822-0296