Provider Demographics
NPI:1548324114
Name:BUSH, DARRACK L (DC)
Entity type:Individual
Prefix:DR
First Name:DARRACK
Middle Name:L
Last Name:BUSH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4857 STATE ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:13476
Mailing Address - Country:US
Mailing Address - Phone:315-953-4103
Mailing Address - Fax:
Practice Address - Street 1:4857 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:NY
Practice Address - Zip Code:13476-3530
Practice Address - Country:US
Practice Address - Phone:315-953-4103
Practice Address - Fax:315-953-4138
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009380111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor