Provider Demographics
NPI:1376742080
Name:MARK A. BLEDSOE
Entity Type:Organization
Organization Name:MARK A. BLEDSOE
Other - Org Name:BLEDSOE FAMILY CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-229-1212
Mailing Address - Street 1:221 6TH AVE SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4362
Mailing Address - Country:US
Mailing Address - Phone:605-229-1212
Mailing Address - Fax:605-229-4440
Practice Address - Street 1:221 6TH AVE SE
Practice Address - Street 2:SUITE 1
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4362
Practice Address - Country:US
Practice Address - Phone:605-229-1212
Practice Address - Fax:605-229-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600240Medicaid
SDS2776Medicare PIN
SDT66559Medicare UPIN