Provider Demographics
NPI:1578542395
Name:CLEMENTS, DEREK MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MICHAEL
Last Name:CLEMENTS
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 1:51060 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4057
Mailing Address - Country:US
Mailing Address - Phone:586-781-4314
Mailing Address - Fax:586-781-4452
Practice Address - Street 1:51060 HAYES RD
Practice Address - Street 2:
Practice Address - City:MACOMB TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48042-4057
Practice Address - Country:US
Practice Address - Phone:586-781-4314
Practice Address - Fax:586-781-4452
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007332111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0170734OtherTOTAL HEALTH CARE
MI95OEO52630OtherBLUE CROSS BLUE SHIELD
MI0M32940Medicare ID - Type Unspecified
MI95OEO52630OtherBLUE CROSS BLUE SHIELD