Provider Demographics
NPI:1790032456
Name:GOLLEY, DEREK J (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:J
Last Name:GOLLEY
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 1:2839 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1330
Mailing Address - Country:US
Mailing Address - Phone:716-873-0500
Mailing Address - Fax:716-873-0500
Practice Address - Street 1:2839 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1330
Practice Address - Country:US
Practice Address - Phone:716-873-0500
Practice Address - Fax:716-873-0500
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-12
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor