1346320736 NPI number — DIANA LYNN SRDICH D.C.

Table of content: DIANA LYNN SRDICH D.C. (NPI 1346320736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346320736 NPI number — DIANA LYNN SRDICH D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SRDICH
Provider First Name:
DIANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLOUGHBY
Provider Other First Name:
DIANA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346320736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8765 W KELTON LN
Provider Second Line Business Mailing Address:
BLDG B-4, SUITE 150
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85382-3584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-979-7100
Provider Business Mailing Address Fax Number:
623-979-3577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8765 W KELTON LN
Provider Second Line Business Practice Location Address:
BLDG B-4, SUITE 150
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85382-3584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-979-7100
Provider Business Practice Location Address Fax Number:
623-979-3577
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  5254 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 350043946 . This is a "RR MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z4643 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0248500 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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