Provider Demographics
NPI:1346320736
Name:SRDICH, DIANA LYNN (DC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:SRDICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:8765 W KELTON LN
Mailing Address - Street 2:BLDG B-4, SUITE 150
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3584
Mailing Address - Country:US
Mailing Address - Phone:623-979-7100
Mailing Address - Fax:623-979-3577
Practice Address - Street 1:8765 W KELTON LN
Practice Address - Street 2:BLDG B-4, SUITE 150
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3584
Practice Address - Country:US
Practice Address - Phone:623-979-7100
Practice Address - Fax:623-979-3577
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5254111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ350043946OtherRR MEDICARE
AZ1Z4643OtherHEALTH NET
AZAZ0248500OtherBLUE CROSS/ BLUE SHIELD
AZ350043946OtherRR MEDICARE
AZ102867Medicare ID - Type Unspecified