Provider Demographics
NPI:1285999524
Name:DERRICK FAMILY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:DERRICK FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:414-328-1734
Mailing Address - Street 1:6508 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2045
Mailing Address - Country:US
Mailing Address - Phone:414-328-1734
Mailing Address - Fax:414-328-3166
Practice Address - Street 1:6508 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-2045
Practice Address - Country:US
Practice Address - Phone:262-227-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4546-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty