Provider Demographics
NPI:1275715435
Name:HEADRICK, STEVEN (DC, DABCO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HEADRICK
Suffix:
Gender:M
Credentials:DC, DABCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1222
Mailing Address - Country:US
Mailing Address - Phone:605-997-3733
Mailing Address - Fax:605-997-3733
Practice Address - Street 1:109 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1222
Practice Address - Country:US
Practice Address - Phone:605-997-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD587111N00000X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600752Medicaid
MN2C985HEOtherBCBSMN
SDP00740093OtherRR MEDICARE PTAN
SD46-0461355OtherFED TAX ID
SDDP2373OtherRR MEDICARE GROUP PTAN
SD7600752Medicaid