Provider Demographics
NPI:1619387339
Name:SIOUX SPINE AND SPORT PROF.L.L.C.
Entity Type:Organization
Organization Name:SIOUX SPINE AND SPORT PROF.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SCHEURENBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:605-362-1230
Mailing Address - Street 1:5412 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-0604
Mailing Address - Country:US
Mailing Address - Phone:605-362-1230
Mailing Address - Fax:605-323-0052
Practice Address - Street 1:5412 W 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-0604
Practice Address - Country:US
Practice Address - Phone:605-362-1230
Practice Address - Fax:605-323-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1024111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS41799Medicare UPIN