Provider Demographics
NPI:1669085338
Name:STACHE, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:STACHE
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 1:1915 WILMAR AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANO
Mailing Address - State:CA
Mailing Address - Zip Code:93445-9362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 BOWSPRIT RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4529
Practice Address - Country:US
Practice Address - Phone:213-915-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician