Provider Demographics
NPI:1124235254
Name:HENDRICKS CHIROPRACTIC PC
Entity type:Organization
Organization Name:HENDRICKS CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-522-2255
Mailing Address - Street 1:663 COUNTY ROAD 17 STE 3
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9329
Mailing Address - Country:US
Mailing Address - Phone:574-522-2255
Mailing Address - Fax:
Practice Address - Street 1:663 CR 17
Practice Address - Street 2:SUITE 3
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9568
Practice Address - Country:US
Practice Address - Phone:574-522-2255
Practice Address - Fax:574-522-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN250620Medicare PIN
INU43964Medicare UPIN