Provider Demographics
NPI:1124296165
Name:DEREK PRICE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:DEREK PRICE CHIROPRACTIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-763-8313
Mailing Address - Street 1:1868 HIWAY 95
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6804
Mailing Address - Country:US
Mailing Address - Phone:928-763-8313
Mailing Address - Fax:928-763-7995
Practice Address - Street 1:1868 HIWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6804
Practice Address - Country:US
Practice Address - Phone:928-763-8313
Practice Address - Fax:928-763-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5736OtherAZ LICENSE
AZU68320OtherUPIN
AZZ103037Medicare PIN