Healthcare Provider Details

I. General information

NPI: 1558238824
Provider Name (Legal Business Name): DERRELL PRATT BLACKBURN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/24/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W UNION HILLS DR STE 7
PHOENIX AZ
85027-6629
US

IV. Provider business mailing address

1717 E UNION HILLS DR UNIT 1079
PHOENIX AZ
85024-3041
US

V. Phone/Fax

Practice location:
  • Phone: 623-492-0999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8834
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: