MEDICARE: DERLETH CHIROPRACTIC PLLC

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	011622	NY

General Provider Information

NPI Number	:	1689818668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERLETH CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	1387 FAIRPORT RD
Second Line	:	SUITE 640
City	:	FAIRPORT
State	:	NY
Zip	:	14450-2003
Country	:	US
Telephone Number	:	585-598-3535
Fax Number	:	585-598-3534

Provider Business Practice Location Address
First Line	:	1387 FAIRPORT RD
Second Line	:	SUITE 640
City	:	FAIRPORT
State	:	NY
Zip	:	14450-2003
Country	:	US
Telephone Number	:	585-598-3535
Fax Number	:	585-598-3534

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR
Name	:	DR. PAULA MARY DERLETH
Credential	:	D.C.
Telephone Number	:	585-598-3535

Provider Enumeration Date	:	04/22/2009
Last Update Date	:	04/22/2009

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