Provider Demographics
NPI:1740276252
Name:VANDEBERG, KEVIN (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:VANDEBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 S CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4817
Mailing Address - Country:US
Mailing Address - Phone:605-335-0880
Mailing Address - Fax:605-335-8506
Practice Address - Street 1:2821 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4817
Practice Address - Country:US
Practice Address - Phone:605-335-0880
Practice Address - Fax:605-335-8506
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00086916OtherRAILROAD MEDICARE PTAN
SD7602052Medicaid
SD7602052Medicaid
SDT66510Medicare UPIN