Provider Demographics
NPI:1205601804
Name:CHRISTIANSEN, BAKE G (LMT)
Entity type:Individual
Prefix:
First Name:BAKE
Middle Name:G
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 JENSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-5259
Mailing Address - Country:US
Mailing Address - Phone:605-882-0100
Mailing Address - Fax:605-882-6911
Practice Address - Street 1:1101 JENSON AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-5259
Practice Address - Country:US
Practice Address - Phone:605-882-0100
Practice Address - Fax:605-882-6911
Is Sole Proprietor?:No
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12857890-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist