Provider Demographics
NPI:1689818668
Name:DERLETH CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:DERLETH CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:DERLETH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:585-598-3535
Mailing Address - Street 1:1387 FAIRPORT RD
Mailing Address - Street 2:SUITE 640
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2003
Mailing Address - Country:US
Mailing Address - Phone:585-598-3535
Mailing Address - Fax:585-598-3534
Practice Address - Street 1:1387 FAIRPORT RD
Practice Address - Street 2:SUITE 640
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2003
Practice Address - Country:US
Practice Address - Phone:585-598-3535
Practice Address - Fax:585-598-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty