MEDICARE: DR. DEBRA MARIE SUNDAHL D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	23030	CA

General Provider Information

NPI Number	:	1396838397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBRA MARIE SUNDAHL D.C.

Provider Business Mailing Address
First Line	:	1960 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1582
Country	:	US
Telephone Number	:	260-489-2266
Fax Number	:	260-490-6565

Provider Business Practice Location Address
First Line	:	1960 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1582
Country	:	US
Telephone Number	:	260-489-2266
Fax Number	:	260-490-6565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/14/2016

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