Provider Demographics
NPI:1992771695
Name:DIERCKS, ALLEN LEE (DC)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:LEE
Last Name:DIERCKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IA
Mailing Address - Zip Code:52722-5727
Mailing Address - Country:US
Mailing Address - Phone:563-355-5942
Mailing Address - Fax:
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:C 1
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-388-9492
Practice Address - Fax:563-388-0019
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0203828Medicaid
IA0203828Medicaid