Provider Demographics
NPI:1992753230
Name:HENDRICKS, DERRICK R (DC)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:R
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 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 COUNTY ROAD 17
Practice Address - Street 2:STE 3
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516
Practice Address - Country:US
Practice Address - Phone:574-522-2255
Practice Address - Fax:574-522-1026
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU43964Medicare UPIN
IN250620AMedicare PIN