Provider Demographics
NPI:1033154307
Name:DIEL, GARY ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:DIEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1151
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0227
Mailing Address - Country:US
Mailing Address - Phone:253-304-5660
Mailing Address - Fax:206-497-8215
Practice Address - Street 1:1406 54TH AVE E
Practice Address - Street 2:SUITE D
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-1284
Practice Address - Country:US
Practice Address - Phone:253-304-5660
Practice Address - Fax:206-497-8215
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG001001395Medicare PIN