Provider Demographics
NPI:1811265895
Name:REVERTS, ABBY L (DC)
Entity type:Individual
Prefix:MS
First Name:ABBY
Middle Name:L
Last Name:REVERTS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SOUTHEAST 10TH STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3569
Mailing Address - Country:US
Mailing Address - Phone:605-556-2002
Mailing Address - Fax:605-556-2012
Practice Address - Street 1:411 SOUTHEAST 10TH STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3569
Practice Address - Country:US
Practice Address - Phone:605-556-2002
Practice Address - Fax:605-556-2012
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1206111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS105474Medicare UPIN