Provider Demographics
NPI:1053461608
Name:DIRKS, STANLEY ALBERT (MS, DC)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:ALBERT
Last Name:DIRKS
Suffix:
Gender:M
Credentials:MS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5048
Mailing Address - Country:US
Mailing Address - Phone:712-328-1625
Mailing Address - Fax:712-388-0389
Practice Address - Street 1:1601 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5167
Practice Address - Country:US
Practice Address - Phone:712-328-1625
Practice Address - Fax:712-388-0389
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0208868Medicaid
IA20886Medicare ID - Type Unspecified