Healthcare Provider Details

I. General information

NPI: 1780811778
Provider Name (Legal Business Name): SIOUX FALLS PHYSICAL MEDICINE AND REHABILITATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 69TH STR. STE 103
SIOUX FALLS SD
57108-2440
US

IV. Provider business mailing address

101 W 69TH STR. STE 103
SIOUX FALLS SD
57108-2440
US

V. Phone/Fax

Practice location:
  • Phone: 605-988-0910
  • Fax: 605-988-0911
Mailing address:
  • Phone: 605-988-0910
  • Fax: 605-988-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number3724
License Number StateSD

VIII. Authorized Official

Name: JERRY J BLOW
Title or Position: OWNER
Credential: MD
Phone: 605-988-0910