Provider Demographics
NPI:1083636773
Name:BERGQUIST, ALAN DAVID (DC)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DAVID
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:1203 E. 4TH AVE. SUITE 101
Mailing Address - City:MILBANK
Mailing Address - State:SD
Mailing Address - Zip Code:57252-0230
Mailing Address - Country:US
Mailing Address - Phone:605-432-9561
Mailing Address - Fax:605-432-9562
Practice Address - Street 1:1203 E. 4TH AVE. SUITE 101
Practice Address - Street 2:
Practice Address - City:MILBANK
Practice Address - State:SD
Practice Address - Zip Code:57252-0230
Practice Address - Country:US
Practice Address - Phone:605-432-9561
Practice Address - Fax:605-432-9562
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD76039303Medicaid
SDS40600Medicare ID - Type Unspecified
SD76039303Medicaid