Provider Demographics
NPI:1114517083
Name:MOLTZ, DEREK LYNN (DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LYNN
Last Name:MOLTZ
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 1:115 N MAIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-2357
Mailing Address - Country:US
Mailing Address - Phone:570-367-1979
Mailing Address - Fax:
Practice Address - Street 1:490 PENNBROOK PKWY
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-3818
Practice Address - Country:US
Practice Address - Phone:215-361-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor