Provider Demographics
NPI:1235148115
Name:DILLER, KIMBERLY LOU (DC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LOU
Last Name:DILLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LOU
Other - Last Name:SAJDAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:208 E WHITLEY ST
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-1506
Mailing Address - Country:US
Mailing Address - Phone:260-693-9644
Mailing Address - Fax:260-693-9644
Practice Address - Street 1:208 E WHITLEY ST
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-1506
Practice Address - Country:US
Practice Address - Phone:260-693-9644
Practice Address - Fax:260-693-9644
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001757A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000375384Medicare UPIN
IN931540Medicare ID - Type Unspecified