Provider Demographics
NPI:1679989743
Name:DEITER, CHELSEA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:DEITER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35147 163RD ST
Mailing Address - Street 2:
Mailing Address - City:FAULKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57438-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 OAK ST
Practice Address - Street 2:
Practice Address - City:FAULKTON
Practice Address - State:SD
Practice Address - Zip Code:57438-2149
Practice Address - Country:US
Practice Address - Phone:605-598-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1747208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5306900Medicaid
SD433401Medicare Oscar/Certification
SDS32025Medicare PIN