Provider Demographics
NPI:1578637666
Name:EKSTROM, RICHARD A (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:EKSTROM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2602
Mailing Address - Country:US
Mailing Address - Phone:605-624-7246
Mailing Address - Fax:605-624-7177
Practice Address - Street 1:1407 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2602
Practice Address - Country:US
Practice Address - Phone:605-624-7246
Practice Address - Fax:605-624-7177
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDPT0923OtherDAKOTACARE
SD4994161OtherWELLMARK BCBS
SD5835180Medicaid
SDPT0923OtherDAKOTACARE