Provider Demographics
NPI:1326000118
Name:KANNEGIETER, ERIC DALE (ATC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DALE
Last Name:KANNEGIETER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 IOWA AVE SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-4031
Mailing Address - Country:US
Mailing Address - Phone:605-352-5264
Mailing Address - Fax:605-352-9776
Practice Address - Street 1:2065 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-3433
Practice Address - Country:US
Practice Address - Phone:605-352-5264
Practice Address - Fax:605-352-9776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD01782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer