Healthcare Provider Details

I. General information

NPI: 1033778451
Provider Name (Legal Business Name): BALANCED SPINE & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6705 W 41ST ST
SIOUX FALLS SD
57106-1290
US

IV. Provider business mailing address

2309 S SADIE AVE
SIOUX FALLS SD
57106-7353
US

V. Phone/Fax

Practice location:
  • Phone: 605-636-5013
  • Fax: 202-967-2307
Mailing address:
  • Phone: 605-681-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TELISHIA DEVERICKS
Title or Position: OWNER/DOCTOR
Credential: DC
Phone: 605-681-4173