Provider Demographics
NPI:1609287630
Name:ANDERSON CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ANDERSON CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-692-6004
Mailing Address - Street 1:223 6TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-1406
Mailing Address - Country:US
Mailing Address - Phone:605-692-6004
Mailing Address - Fax:605-692-6003
Practice Address - Street 1:223 6TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1406
Practice Address - Country:US
Practice Address - Phone:605-692-6004
Practice Address - Fax:605-692-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1005696Medicaid
SD1005696Medicaid