Provider Demographics
NPI:1093707911
Name:DIETRICH, L. ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:L.
Middle Name:ANTHONY
Last Name:DIETRICH
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 1:1605 W KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5532
Mailing Address - Country:US
Mailing Address - Phone:563-386-4798
Mailing Address - Fax:563-386-0903
Practice Address - Street 1:1605 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5532
Practice Address - Country:US
Practice Address - Phone:563-386-4798
Practice Address - Fax:563-386-0903
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1289728Medicaid
IA1289728Medicaid
IAI17324Medicare PIN