Provider Demographics
NPI:1437311701
Name:WALLERY, DERRICK D (DC)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:D
Last Name:WALLERY
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 1:4176 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2161
Mailing Address - Country:US
Mailing Address - Phone:773-283-3131
Mailing Address - Fax:773-283-3610
Practice Address - Street 1:4176 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2161
Practice Address - Country:US
Practice Address - Phone:773-283-3131
Practice Address - Fax:773-283-3610
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008088111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor