Provider Demographics
NPI:1669790655
Name:DERKACH, JEFFREY H (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:H
Last Name:DERKACH
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 1:8618 S SEPULVEDA BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4024
Mailing Address - Country:US
Mailing Address - Phone:310-649-5894
Mailing Address - Fax:310-649-5304
Practice Address - Street 1:8618 S SEPULVEDA BLVD
Practice Address - Street 2:130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4005
Practice Address - Country:US
Practice Address - Phone:310-649-5894
Practice Address - Fax:310-649-5304
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17889111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor