Provider Demographics
NPI:1346345840
Name:BACK SPECIALISTS OF THE MIDWEST LLC
Entity Type:Organization
Organization Name:BACK SPECIALISTS OF THE MIDWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:JON
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-361-1700
Mailing Address - Street 1:5109 S CROSSING PL
Mailing Address - Street 2:STE 1
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5076
Mailing Address - Country:US
Mailing Address - Phone:605-361-1700
Mailing Address - Fax:605-361-0113
Practice Address - Street 1:5109 S CROSSING PL
Practice Address - Street 2:STE 1
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5076
Practice Address - Country:US
Practice Address - Phone:605-361-1700
Practice Address - Fax:605-361-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD714111N00000X
SD1351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD101558Medicare PIN