Provider Demographics
NPI:1205848108
Name:SOUTHRIDGE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:SOUTHRIDGE CHIROPRACTIC PC
Other - Org Name:SOUTHRIDGE CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TEN BROEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-258-8388
Mailing Address - Street 1:425 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5801
Mailing Address - Country:US
Mailing Address - Phone:701-258-8388
Mailing Address - Fax:701-258-8788
Practice Address - Street 1:425 S 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5801
Practice Address - Country:US
Practice Address - Phone:701-258-8388
Practice Address - Fax:701-258-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17897Medicaid
ND572001OtherBCBS OF ND
ND17897Medicaid