MEDICARE: STACEY ANNE DERSHAM D.C.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	111N00000X	Chiropractor	001788	CT

General Provider Information

NPI Number	:	1871753228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY ANNE DERSHAM D.C.

Provider Business Mailing Address
First Line	:	113 BRALEY HILL RD
Second Line	:
City	:	ROCHESTER
State	:	MA
Zip	:	02770-1917
Country	:	US
Telephone Number	:	508-725-8307
Fax Number	:

Provider Business Practice Location Address
First Line	:	657 PLEASANT ST
Second Line	:	BOX #5
City	:	FALL RIVER
State	:	MA
Zip	:	02721-4323
Country	:	US
Telephone Number	:	508-677-2554
Fax Number	:	508-677-2553

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

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	11/20/2013

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