Provider Demographics
NPI:1295578144
Name:DERICKS, THOMAS JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:DERICKS
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 1:640 PINEY RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3100
Mailing Address - Country:US
Mailing Address - Phone:985-705-5032
Mailing Address - Fax:
Practice Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD STE 201
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4960
Practice Address - Country:US
Practice Address - Phone:985-893-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1999111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor