Provider Demographics
NPI:1811957764
Name:CHESMORE, KIP D (RPT)
Entity type:Individual
Prefix:
First Name:KIP
Middle Name:D
Last Name:CHESMORE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5312
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:575 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5312
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:605-217-2900
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA31824OtherBCBS IOWA
NE421480644-34Medicaid
SD4993432OtherBCBS SOUTH DAKOTA
IA0763219Medicaid
SD5833242Medicaid
IA0763219Medicaid
SD5833242Medicaid