Healthcare Provider Details

I. General information

NPI: 1285171132
Provider Name (Legal Business Name): BENJAMIN MORRIS GANNON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E 23RD ST
SIOUX FALLS SD
57105-2135
US

IV. Provider business mailing address

1112 W 27TH ST
SIOUX FALLS SD
57105-2707
US

V. Phone/Fax

Practice location:
  • Phone: 605-331-5890
  • Fax:
Mailing address:
  • Phone: 510-220-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0724
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: