Provider Demographics
NPI:1467690073
Name:DIECKOW, LANE DAVID
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:DAVID
Last Name:DIECKOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:3714 N PROSPECT RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7743
Practice Address - Country:US
Practice Address - Phone:309-550-7888
Practice Address - Fax:309-550-7848
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist