Healthcare Provider Details

I. General information

NPI: 1861971806
Provider Name (Legal Business Name): CRISTIAN JEREMIAH VAN DYKE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W OMAHA ST STE 3
RAPID CITY SD
57701-8119
US

IV. Provider business mailing address

1001 E 5TH AVE
MITCHELL SD
57301-2915
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-5950
  • Fax: 605-721-5940
Mailing address:
  • Phone: 605-630-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2081
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: