Provider Demographics
NPI:1922099316
Name:GUDMUNDSEN, DIANE S (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:S
Last Name:GUDMUNDSEN
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 1:4004 SW KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4389
Mailing Address - Country:US
Mailing Address - Phone:503-223-5152
Mailing Address - Fax:503-224-3454
Practice Address - Street 1:4004 SW KELLY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4389
Practice Address - Country:US
Practice Address - Phone:503-223-5152
Practice Address - Fax:503-224-3454
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T67684Medicare UPIN
00000QGDBGMedicare ID - Type Unspecified