Healthcare Provider Details

I. General information

NPI: 1518085745
Provider Name (Legal Business Name): GARY ALLEN DERBY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S MAIN ST # 105
ALBIA IA
52531-2059
US

IV. Provider business mailing address

201 S MAIN ST # 105
ALBIA IA
52531-2059
US

V. Phone/Fax

Practice location:
  • Phone: 641-521-4143
  • Fax:
Mailing address:
  • Phone: 641-521-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number4804
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: