Provider Demographics
NPI:1982169165
Name:DERILUS, MARIE J
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:J
Last Name:DERILUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E OLD BOWMAN RD STE C
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2296
Mailing Address - Country:US
Mailing Address - Phone:512-589-2702
Mailing Address - Fax:
Practice Address - Street 1:102 E OLD BOWMAN RD STE C
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2296
Practice Address - Country:US
Practice Address - Phone:512-589-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13954111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty