Provider Demographics
NPI:1891014411
Name:DERRICK FAMILY CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:DERRICK FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-438-6425
Mailing Address - Street 1:3535 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5049
Mailing Address - Country:US
Mailing Address - Phone:360-491-9135
Mailing Address - Fax:360-923-9382
Practice Address - Street 1:3535 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5049
Practice Address - Country:US
Practice Address - Phone:360-438-6425
Practice Address - Fax:360-923-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115000627Medicare PIN