Provider Demographics
NPI:1629076435
Name:BLUDORN, JERAD ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JERAD
Middle Name:ROBERT
Last Name:BLUDORN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 MAIN AVE
Mailing Address - Street 2:PO BOX 252
Mailing Address - City:LAKE NORDEN
Mailing Address - State:SD
Mailing Address - Zip Code:57248-0252
Mailing Address - Country:US
Mailing Address - Phone:605-785-3900
Mailing Address - Fax:605-785-3908
Practice Address - Street 1:505 MAIN AVE
Practice Address - Street 2:
Practice Address - City:LAKE NORDEN
Practice Address - State:SD
Practice Address - Zip Code:57248-0252
Practice Address - Country:US
Practice Address - Phone:605-785-3900
Practice Address - Fax:605-785-3908
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4995423OtherBCBS
SD7601960Medicaid
100139Medicare ID - Type Unspecified
SD7601960Medicaid