Provider Demographics
NPI:1609967579
Name:DIETSCHE, LORI L (DC)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:L
Last Name:DIETSCHE
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 1:1258 N SAN DIMAS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1223
Mailing Address - Country:US
Mailing Address - Phone:909-305-1231
Mailing Address - Fax:909-305-0432
Practice Address - Street 1:1258 N SAN DIMAS CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1223
Practice Address - Country:US
Practice Address - Phone:909-305-1231
Practice Address - Fax:909-305-0432
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22645111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6585831Medicaid
CADC22645Medicare ID - Type Unspecified