Provider Demographics
NPI:1194006189
Name:BENNER, DERRICK JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:JAMES
Last Name:BENNER
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 1:226 BRANDILYNN BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-7410
Mailing Address - Country:US
Mailing Address - Phone:319-277-1819
Mailing Address - Fax:319-277-1907
Practice Address - Street 1:226 BRANDILYNN BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-7410
Practice Address - Country:US
Practice Address - Phone:319-277-1819
Practice Address - Fax:319-277-1907
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor