Basic Information
| Provider Information | |||||||||
| NPI: | 1326024977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANBRIDGE | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5974 FASHION POINT DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014756800 | ||||||||
| FaxNumber: | 8014756802 | ||||||||
| Practice Location | |||||||||
| Address1: | 5974 FASHION POINT DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014756800 | ||||||||
| FaxNumber: | 8014756802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/16/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 48041471202 | UT | Y | Chiropractic Providers | Chiropractor |
No ID Information.