1124198593 NPI number — DR. DERIK NELSON BALTICH D.C.

Table of content: DR. DERIK NELSON BALTICH D.C. (NPI 1124198593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124198593 NPI number — DR. DERIK NELSON BALTICH D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALTICH
Provider First Name:
DERIK
Provider Middle Name:
NELSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124198593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 JOE V KNOX AVENUE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-799-1999
Provider Business Mailing Address Fax Number:
704-663-8225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1086 RIVER HWY
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-9147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-799-1999
Provider Business Practice Location Address Fax Number:
704-663-8225
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3047 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89085MF , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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