Provider Demographics
NPI:1720339526
Name:IVERSON, BRIAN DALE (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DALE
Last Name:IVERSON
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1210 W 18TH ST
Mailing Address - Street 2:SUITE LL01
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4647
Mailing Address - Country:US
Mailing Address - Phone:605-328-1860
Mailing Address - Fax:605-328-1857
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:SUITE LL01
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4647
Practice Address - Country:US
Practice Address - Phone:605-328-1860
Practice Address - Fax:605-328-1857
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD0787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist