Provider Demographics
NPI:1104398171
Name:GORACKE, DEREK (DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:GORACKE
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 1:510 22ND AVE E STE 701
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-4817
Mailing Address - Country:US
Mailing Address - Phone:320-763-9711
Mailing Address - Fax:
Practice Address - Street 1:510 22ND AVE E STE 701
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4817
Practice Address - Country:US
Practice Address - Phone:320-763-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor