Provider Demographics
NPI:1912374596
Name:MELSTROM, ADAM JOSEPH (ATC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:MELSTROM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SDSU
Mailing Address - Street 2:2810 HPER CENTER
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57007-1497
Mailing Address - Country:US
Mailing Address - Phone:605-688-4003
Mailing Address - Fax:
Practice Address - Street 1:SDSU
Practice Address - Street 2:2810 HPER CENTER
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-1497
Practice Address - Country:US
Practice Address - Phone:605-688-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD05232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program