Provider Demographics
NPI:1124198593
Name:BALTICH, DERIK NELSON (DC)
Entity Type:Individual
Prefix:DR
First Name:DERIK
Middle Name:NELSON
Last Name:BALTICH
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 1:206 JOE V KNOX AVENUE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-799-1999
Mailing Address - Fax:704-663-8225
Practice Address - Street 1:1086 RIVER HWY
Practice Address - Street 2:SUITE D
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9147
Practice Address - Country:US
Practice Address - Phone:704-799-1999
Practice Address - Fax:704-663-8225
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085MFMedicaid
NC89085MFMedicaid
NCU91808Medicare UPIN