Healthcare Provider Details

I. General information

NPI: 1972800514
Provider Name (Legal Business Name): DERICK LEE TIBBETTS IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 S WHITTIER ST
WICHITA KS
67207-2222
US

IV. Provider business mailing address

638 S WHITTIER ST
WICHITA KS
67207-2222
US

V. Phone/Fax

Practice location:
  • Phone: 316-841-3810
  • Fax:
Mailing address:
  • Phone: 316-841-3810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: