Provider Demographics
NPI:1396838397
Name:SUNDAHL, DEBRA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:MARIE
Last Name:SUNDAHL
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 1:1960 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1582
Mailing Address - Country:US
Mailing Address - Phone:260-489-2266
Mailing Address - Fax:260-490-6565
Practice Address - Street 1:1960 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1582
Practice Address - Country:US
Practice Address - Phone:260-489-2266
Practice Address - Fax:260-490-6565
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU56583Medicare UPIN
CAU56583Medicare UPIN