Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 08000910 | IN |
NPI | 1245363696 |
---|---|
Provider Name | Dr. Michael John Dibley JR. |
First Address | Elkhart, IN 46514-6606 |
Second Address | Elkhart, IN 46514-6606 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T34626 | (02) | IN |