Provider Demographics
NPI:1780732172
Name:CANYON WELLNESS AND CHIROPRACTIC
Entity type:Organization
Organization Name:CANYON WELLNESS AND CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-722-4525
Mailing Address - Street 1:710 E COLORADO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-4701
Mailing Address - Country:US
Mailing Address - Phone:605-722-4525
Mailing Address - Fax:605-722-4533
Practice Address - Street 1:710 E COLORADO BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-4701
Practice Address - Country:US
Practice Address - Phone:605-722-4525
Practice Address - Fax:605-722-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD954111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDT35357Medicare UPIN