Provider Demographics
NPI:1154454288
Name:DIBALLA, SUSAN (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DIBALLA
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 1:699 HAMPSHIRE RD
Mailing Address - Street 2:#109
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2379
Mailing Address - Country:US
Mailing Address - Phone:805-497-1918
Mailing Address - Fax:805-495-4946
Practice Address - Street 1:699 HAMPSHIRE RD
Practice Address - Street 2:#109
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2379
Practice Address - Country:US
Practice Address - Phone:805-497-1918
Practice Address - Fax:805-495-4946
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21298Medicare ID - Type UnspecifiedCHIROPRACTOR