Provider Demographics
NPI:1457961922
Name:CHI, DERRICK CHE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:CHE
Last Name:CHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 STONEHEDGE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2107
Mailing Address - Country:US
Mailing Address - Phone:937-715-9715
Mailing Address - Fax:
Practice Address - Street 1:4807 STONEHEDGE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-2107
Practice Address - Country:US
Practice Address - Phone:937-715-9715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH420555163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty