MEDICARE: DR. JEFFREY H DERKACH DC

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	17889	CA

General Provider Information

NPI Number	:	1669790655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY H DERKACH DC

Provider Business Mailing Address
First Line	:	8618 S SEPULVEDA BLVD STE 130
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4024
Country	:	US
Telephone Number	:	310-649-5894
Fax Number	:	310-649-5304

Provider Business Practice Location Address
First Line	:	8618 S SEPULVEDA BLVD
Second Line	:	130
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4005
Country	:	US
Telephone Number	:	310-649-5894
Fax Number	:	310-649-5304

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

Provider Enumeration Date	:	05/14/2010
Last Update Date	:	05/14/2010

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