Provider Demographics
NPI:1760597116
Name:CRISMAN DIXON & ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:CRISMAN DIXON & ASSOCIATES, P.C.
Other - Org Name:BACK TO HEALTH WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CRISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-718-7312
Mailing Address - Street 1:343 QUINCY STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3700
Mailing Address - Country:US
Mailing Address - Phone:605-718-7312
Mailing Address - Fax:605-718-9008
Practice Address - Street 1:343 QUINCY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3700
Practice Address - Country:US
Practice Address - Phone:605-718-7312
Practice Address - Fax:605-718-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD774261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600534Medicaid
SDS41463Medicare ID - Type UnspecifiedGROUP
SD7600534Medicaid
SDS41464Medicare PIN