Provider Demographics
NPI:1861511479
Name:CHIROSPORT PC
Entity Type:Organization
Organization Name:CHIROSPORT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-201-9191
Mailing Address - Street 1:128 E HOLLY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1114
Mailing Address - Country:US
Mailing Address - Phone:605-582-8800
Mailing Address - Fax:
Practice Address - Street 1:128 E HOLLY BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1114
Practice Address - Country:US
Practice Address - Phone:605-582-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDC1019111N00000X
SD1019111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7601810Medicaid
SD4995646OtherBCBS PROVIDER NUMBER
SDU98680Medicare UPIN
SD7601810Medicaid
SDS41726Medicare PIN