Provider Demographics
NPI:1801187703
Name:JOSEPH, DERRICK VINCENT (DC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:VINCENT
Last Name:JOSEPH
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 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:7606 FALLBROOK AVE
Practice Address - Street 2:4
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91304-3610
Practice Address - Country:US
Practice Address - Phone:818-457-9948
Practice Address - Fax:818-887-1577
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20646111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20646OtherCHIROPRACTIC LICENSE
CAFA266AOtherPTAN