Healthcare Provider Details

I. General information

NPI: 1922426303
Provider Name (Legal Business Name): DERREK LEONARD MART D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28470 LA 43 HWY SUITE B
ALBANY LA
70711-4322
US

IV. Provider business mailing address

10920 AIRLINE HWY APT 145
BATON ROUGE LA
70816-4288
US

V. Phone/Fax

Practice location:
  • Phone: 225-567-6651
  • Fax:
Mailing address:
  • Phone: 337-802-2608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1701
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: