Provider Demographics
NPI:1104244375
Name:GENESIS FAMILY CHIROPRACTIC INC
Entity type:Organization
Organization Name:GENESIS FAMILY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:DARREL
Authorized Official - Last Name:INGALLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-334-0900
Mailing Address - Street 1:5109 S CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5443
Mailing Address - Country:US
Mailing Address - Phone:605-334-0900
Mailing Address - Fax:605-334-0910
Practice Address - Street 1:5109 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5443
Practice Address - Country:US
Practice Address - Phone:605-334-0900
Practice Address - Fax:605-334-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1154696060OtherMEDICARE NPI