Provider Demographics
NPI:1043342348
Name:COLLINS, DEREK LANCE (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LANCE
Last Name:COLLINS
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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0280
Mailing Address - Country:US
Mailing Address - Phone:580-371-3330
Mailing Address - Fax:580-371-3694
Practice Address - Street 1:109 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2337
Practice Address - Country:US
Practice Address - Phone:580-371-3330
Practice Address - Fax:580-371-3694
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT12743Medicare UPIN