Provider Demographics
NPI:1790947273
Name:DERRYBERRY HEALTH PLLC
Entity Type:Organization
Organization Name:DERRYBERRY HEALTH PLLC
Other - Org Name:DERRYBERRY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROC
Authorized Official - Middle Name:SLATER
Authorized Official - Last Name:DERRYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-701-5777
Mailing Address - Street 1:1200 12TH AVE SE
Mailing Address - Street 2:#136
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2497
Mailing Address - Country:US
Mailing Address - Phone:405-701-5777
Mailing Address - Fax:405-701-5778
Practice Address - Street 1:1200 12TH AVE SE
Practice Address - Street 2:136
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-2497
Practice Address - Country:US
Practice Address - Phone:405-701-5777
Practice Address - Fax:405-701-5778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK24M716605Medicare PIN