Provider Demographics
NPI:1265045165
Name:HINES, DEREK TYLER (DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:TYLER
Last Name:HINES
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 1:5034 HAWK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-5729
Mailing Address - Country:US
Mailing Address - Phone:405-664-3394
Mailing Address - Fax:
Practice Address - Street 1:5962 STETSON HILLS BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3579
Practice Address - Country:US
Practice Address - Phone:719-596-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0008239111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor