Provider Demographics
NPI:1922196047
Name:SUNDERLAGE, DIANE MARIE (DC LAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:SUNDERLAGE
Suffix:
Gender:F
Credentials:DC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 N SEMINARY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2959
Mailing Address - Country:US
Mailing Address - Phone:815-338-6650
Mailing Address - Fax:815-338-6652
Practice Address - Street 1:1114 N SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2959
Practice Address - Country:US
Practice Address - Phone:815-338-6650
Practice Address - Fax:815-338-6652
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005682017OtherBCBS
T37655Medicare UPIN
IL669290Medicare ID - Type Unspecified