Provider Demographics
NPI:1083763593
Name:SOUDER, VICKI LEA (DC)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:LEA
Last Name:SOUDER
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 1:419 N. GRANDVIEW AVE.
Mailing Address - Street 2:STE 200
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001
Mailing Address - Country:US
Mailing Address - Phone:563-585-0800
Mailing Address - Fax:
Practice Address - Street 1:419 N. GRANDVIEW AVE.
Practice Address - Street 2:STE 200
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001
Practice Address - Country:US
Practice Address - Phone:563-585-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA37998OtherWELLMARK
IA0456202Medicaid
IAI14543Medicare ID - Type Unspecified