Healthcare Provider Details

I. General information

NPI: 1225449937
Provider Name (Legal Business Name): DERRICK NOHL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 MACKENZIE RD
AFFTON MO
63123-3518
US

IV. Provider business mailing address

450 WATERSIDE DR
GROVER MO
63040-1618
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-4500
  • Fax:
Mailing address:
  • Phone: 636-422-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2013042355
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: