Healthcare Provider Details

I. General information

NPI: 1164703039
Provider Name (Legal Business Name): DERRICK J. BENNER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 BRANDILYNN BLVD
CEDAR FALLS IA
50613-7410
US

IV. Provider business mailing address

226 BRANDILYNN BLVD
CEDAR FALLS IA
50613-7410
US

V. Phone/Fax

Practice location:
  • Phone: 319-277-1819
  • Fax: 319-277-1907
Mailing address:
  • Phone: 319-277-1819
  • Fax: 319-277-1907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number007451
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number007451
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DERRICK JAMES BENNER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 319-243-8393