Provider Demographics
NPI:1144303926
Name:NELSON, KENT E (PT)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:E
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 SOUTH PORTICE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103
Mailing Address - Country:US
Mailing Address - Phone:605-371-3908
Mailing Address - Fax:
Practice Address - Street 1:101 WEST 69TH STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-331-0044
Practice Address - Fax:605-331-0088
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5832100Medicaid
SDS6000Medicare ID - Type Unspecified