Healthcare Provider Details

I. General information

NPI: 1124235254
Provider Name (Legal Business Name): HENDRICKS CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 CR 17 SUITE 3
ELKHART IN
46516-9568
US

IV. Provider business mailing address

663 COUNTY ROAD 17 STE 3
ELKHART IN
46516-9329
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-2255
  • Fax: 574-522-1026
Mailing address:
  • Phone: 574-522-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001451
License Number StateIN

VIII. Authorized Official

Name: DR. DERRICK R. HENDRICKS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 574-522-2255