Provider Demographics
NPI:1922711258
Name:IERINO, DEREK (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:IERINO
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 1:1221 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3397
Mailing Address - Country:US
Mailing Address - Phone:612-874-0705
Mailing Address - Fax:
Practice Address - Street 1:1221 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3397
Practice Address - Country:US
Practice Address - Phone:612-874-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7063111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor