Provider Demographics
NPI:1255896072
Name:DYNAMIC CHIROPRACTIC PROF LLC
Entity type:Organization
Organization Name:DYNAMIC CHIROPRACTIC PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, MANAGER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIVERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-661-9639
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:PARKSTON
Mailing Address - State:SD
Mailing Address - Zip Code:57366-0417
Mailing Address - Country:US
Mailing Address - Phone:605-661-9639
Mailing Address - Fax:
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PARKSTON
Practice Address - State:SD
Practice Address - Zip Code:57366
Practice Address - Country:US
Practice Address - Phone:605-928-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1154752640Medicaid