Provider Demographics
NPI:1629480090
Name:SHORT, TINA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:HENDERSCHIEDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:5015 S WESTERN AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5025
Mailing Address - Country:US
Mailing Address - Phone:605-977-6223
Mailing Address - Fax:605-335-0014
Practice Address - Street 1:5015 S WESTERN AVE STE 160
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5025
Practice Address - Country:US
Practice Address - Phone:605-977-6223
Practice Address - Fax:605-335-0014
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1246111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD162942067689OtherINDIVIDUAL NPI