Provider Demographics
NPI:1538386511
Name:BLICKENSDERFER CHIROPRACTIC P C
Entity type:Organization
Organization Name:BLICKENSDERFER CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLICKENSDERFER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-343-1113
Mailing Address - Street 1:2326 CANYON LAKE DR
Mailing Address - Street 2:STE 7
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2913
Mailing Address - Country:US
Mailing Address - Phone:605-343-1113
Mailing Address - Fax:605-342-8424
Practice Address - Street 1:2326 CANYON LAKE DR
Practice Address - Street 2:STE 7
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2913
Practice Address - Country:US
Practice Address - Phone:605-343-1113
Practice Address - Fax:605-342-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0006076OtherBLUE CROSS BLUE SHIELD
SD7603190Medicaid
SDS6076OtherMEDICARE B
SDU13737Medicare UPIN