Provider Demographics
NPI:1073028544
Name:DEEP ROOTS CHIROPRACTIC
Entity type:Organization
Organization Name:DEEP ROOTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:UPPER CERVICAL CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MEANS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-275-6900
Mailing Address - Street 1:1010 E SUNRISE PL APT 105B
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8413
Mailing Address - Country:US
Mailing Address - Phone:712-369-3068
Mailing Address - Fax:
Practice Address - Street 1:4944 E 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8705
Practice Address - Country:US
Practice Address - Phone:605-275-6900
Practice Address - Fax:605-275-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty