Healthcare Provider Details

I. General information

NPI: 1346320736
Provider Name (Legal Business Name): DIANA LYNN SRDICH D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA LYNN WILLOUGHBY DC

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 W KELTON LN BLDG B-4, SUITE 150
PEORIA AZ
85382-3584
US

IV. Provider business mailing address

8765 W KELTON LN BLDG B-4, SUITE 150
PEORIA AZ
85382-3584
US

V. Phone/Fax

Practice location:
  • Phone: 623-979-7100
  • Fax: 623-979-3577
Mailing address:
  • Phone: 623-979-7100
  • Fax: 623-979-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number5254
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: