Provider Demographics
NPI:1750028585
Name:DIEBOLD, TANNER MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:MICHAEL
Last Name:DIEBOLD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2644
Mailing Address - Country:US
Mailing Address - Phone:909-767-9896
Mailing Address - Fax:
Practice Address - Street 1:2816 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1401
Practice Address - Country:US
Practice Address - Phone:909-767-9896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty