Healthcare Provider Details

I. General information

NPI: 1629326905
Provider Name (Legal Business Name): DEREK WADE STICKLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2447 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

IV. Provider business mailing address

2447 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

V. Phone/Fax

Practice location:
  • Phone: 254-394-0836
  • Fax:
Mailing address:
  • Phone: 254-394-0836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6888
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6888
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: