Basic Information
| Provider Information | |||||||||
| NPI: | 1467690073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIECKOW | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305751980 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3714 N PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616147743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095507888 | ||||||||
| FaxNumber: | 3095507848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070016884 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.