Provider Demographics
NPI:1457699761
Name:HEALTHSOURCE OF SIOUX FALLS WEST PC
Entity type:Organization
Organization Name:HEALTHSOURCE OF SIOUX FALLS WEST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-275-0040
Mailing Address - Street 1:6705 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-1290
Mailing Address - Country:US
Mailing Address - Phone:605-275-0040
Mailing Address - Fax:605-275-0041
Practice Address - Street 1:6705 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-1290
Practice Address - Country:US
Practice Address - Phone:605-275-0040
Practice Address - Fax:605-275-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty