Provider Demographics
NPI:1194277582
Name:BARK, DERRICK (DC, ATC)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:BARK
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 WOODGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-5031
Mailing Address - Country:US
Mailing Address - Phone:937-570-7110
Mailing Address - Fax:
Practice Address - Street 1:344 WOODGREEN DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-5031
Practice Address - Country:US
Practice Address - Phone:937-570-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MO2023000539111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer