Provider Demographics
NPI:1124577234
Name:KACZOR, DEREK PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:PATRICK
Last Name:KACZOR
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 1:481 PIN OAK CT
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3391
Mailing Address - Country:US
Mailing Address - Phone:470-262-3107
Mailing Address - Fax:
Practice Address - Street 1:15175 S DIXIE HWY STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-5038
Practice Address - Country:US
Practice Address - Phone:734-244-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP029240Medicaid