Healthcare Provider Details

I. General information

NPI: 1417581539
Provider Name (Legal Business Name): DEREK MARRONGELLE DACM, L.AC., CCN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16421 N TATUM BLVD STE 210
PHOENIX AZ
85032-3457
US

IV. Provider business mailing address

113 PINE CREEK DR
ORWIGSBURG PA
17961-9135
US

V. Phone/Fax

Practice location:
  • Phone: 570-617-9005
  • Fax:
Mailing address:
  • Phone: 570-617-9005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberLAC-010133
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number5063
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: