MEDICARE: DEREK WAYNE BIRCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4865482-1202	UT

General Provider Information

NPI Number	:	1174569248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK WAYNE BIRCH

Provider Business Mailing Address
First Line	:	420 W 2450 N
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-3118
Country	:	US
Telephone Number	:	801-768-1445
Fax Number	:

Provider Business Practice Location Address
First Line	:	2364 W 12600 S
Second Line	:
City	:	RIVERTON
State	:	UT
Zip	:	84065-7109
Country	:	US
Telephone Number	:	801-446-2131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	07/08/2007

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