Provider Demographics
NPI:1073643466
Name:DIETRICK, LUCILLE A (DC)
Entity Type:Individual
Prefix:DR
First Name:LUCILLE
Middle Name:A
Last Name:DIETRICK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CONGRESS PKWY N
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-1618
Mailing Address - Country:US
Mailing Address - Phone:423-746-4544
Mailing Address - Fax:
Practice Address - Street 1:620 CONGRESS PKWY N
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-1618
Practice Address - Country:US
Practice Address - Phone:423-746-4544
Practice Address - Fax:423-746-4545
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1348111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3151639OtherBCBS
TN648850OtherACN
TN3151639OtherBCBS
TN648850OtherACN