Provider Demographics
NPI:1790710796
Name:BLEDSOE, MARK A (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:BLEDSOE
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 1:221 6TH AVE SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4362
Mailing Address - Country:US
Mailing Address - Phone:605-229-1212
Mailing Address - Fax:605-229-4440
Practice Address - Street 1:221 6TH AVE SE
Practice Address - Street 2:SUITE 1
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4362
Practice Address - Country:US
Practice Address - Phone:605-229-1212
Practice Address - Fax:605-229-4440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD653111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600240Medicaid
SDS2776Medicare ID - Type UnspecifiedMEDICARE
SDT66559Medicare UPIN