Provider Demographics
NPI:1245363696
Name:DIBLEY, MICHAEL JOHN JR (DC,CCSP)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:DIBLEY
Suffix:JR
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 E. BRISTOL ST.
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6606
Mailing Address - Country:US
Mailing Address - Phone:574-264-9174
Mailing Address - Fax:574-262-4070
Practice Address - Street 1:1709 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6606
Practice Address - Country:US
Practice Address - Phone:574-264-9174
Practice Address - Fax:574-262-4070
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000910111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT34626Medicare UPIN
IN225360Medicare ID - Type Unspecified