Provider Demographics
NPI:1538766597
Name:HUDDLESTON, BILLY DEREK
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:DEREK
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11668 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-9353
Mailing Address - Country:US
Mailing Address - Phone:501-366-1919
Mailing Address - Fax:
Practice Address - Street 1:11668 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-9353
Practice Address - Country:US
Practice Address - Phone:501-366-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2022-08-18
Deactivation Date:2022-07-28
Deactivation Code:
Reactivation Date:2022-08-18
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.61178122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor