Provider Demographics
NPI:1730271065
Name:DEROCHER, NICHOLAS JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:DEROCHER
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 1:70 E HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-5011
Mailing Address - Country:US
Mailing Address - Phone:515-978-8889
Mailing Address - Fax:515-978-0009
Practice Address - Street 1:70 E HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-5011
Practice Address - Country:US
Practice Address - Phone:515-978-8889
Practice Address - Fax:515-978-0009
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0462150Medicaid
IAI14683Medicare ID - Type Unspecified