Basic Information
| Provider Information | |||||||||
| NPI: | 1306581434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEDERICH | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21439 W 121ST ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660615601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857476315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162343000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2022 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 05-35604 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 24-01018 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.