Provider Demographics
NPI:1194806877
Name:DERBY, KIM (DC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DERBY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 HOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-4641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 PIRKLE FERRY RD
Practice Address - Street 2:SUITE A-200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2545
Practice Address - Country:US
Practice Address - Phone:770-776-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U79022Medicare UPIN