Provider Demographics
NPI:1508233735
Name:LIBBY, DEREK (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:LIBBY
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 1:12237 POWAY RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4217
Mailing Address - Country:US
Mailing Address - Phone:858-486-3400
Mailing Address - Fax:
Practice Address - Street 1:12237 POWAY RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-4217
Practice Address - Country:US
Practice Address - Phone:858-486-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor