Provider Demographics
NPI:1811318470
Name:KRUCKENBERG, TRACEY LYNNE (DC)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNNE
Last Name:KRUCKENBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:LYNNE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:5015 S WESTERN AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5025
Mailing Address - Country:US
Mailing Address - Phone:605-271-8160
Mailing Address - Fax:605-271-8162
Practice Address - Street 1:5015 S WESTERN AVE STE 160
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5025
Practice Address - Country:US
Practice Address - Phone:605-271-8160
Practice Address - Fax:605-271-8186
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1339111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDLICENSEOther1339
SD1339OtherSTATE LICENSE
SD1801166889OtherNPI