Basic Information
| Provider Information | |||||||||
| NPI: | 1811957764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHESMORE | ||||||||
| FirstName: | KIP | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | R.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 N SIOUX POINT RD | ||||||||
| Address2: | |||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052172667 | ||||||||
| FaxNumber: | 6052172900 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 N SIOUX POINT RD | ||||||||
| Address2: | |||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052172667 | ||||||||
| FaxNumber: | 6052172900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0821 | SD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 31824 | 01 | IA | BCBS IOWA | OTHER | 421480644-34 | 05 | NE | MEDICAID | 4993432 | 01 | SD | BCBS SOUTH DAKOTA | OTHER | 0763219 | 05 | IA | MEDICAID | 5833242 | 05 | SD | MEDICAID |