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General NPI Number Information
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NPI Number | 1861511479
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Entity Type | Organization
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Legal Business Name | CHIROSPORT PC
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 09/05/2012
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Provider Practice Location Address
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Address Line | 128 E HOLLY BLVD
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City | BRANDON
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State | SD
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Zip | 57005-1114
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Country | US
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Telephone | 605-582-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 128 E HOLLY BLVD
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City | BRANDON
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State | SD
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Zip | 57005-1114
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Country | US
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Telephone | 605-582-8800
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Fax |
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Authorized Official
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Title or Position | CLINIC MANAGER
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Name | PAIGE M HONNER
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Credential |
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Telephone | 605-201-9191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 1019
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | C1019
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License Number State | SD
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