Provider Demographics
NPI:1992776876
Name:DAKOTA CHIROPRACTIC & WELLNESS CENTER PROF LLC
Entity type:Organization
Organization Name:DAKOTA CHIROPRACTIC & WELLNESS CENTER PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-339-3300
Mailing Address - Street 1:5124 S WESTERN AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108
Mailing Address - Country:US
Mailing Address - Phone:605-339-3300
Mailing Address - Fax:605-339-8880
Practice Address - Street 1:5124 S WESTERN AVE
Practice Address - Street 2:STE 1
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-339-3300
Practice Address - Fax:605-339-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1009111N00000X
SD1008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS41530Medicare PIN