Basic Information
| Provider Information | |||||||||
| NPI: | 1538822093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERRICK | ||||||||
| FirstName: | BROCK | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOVA | ||||||||
| OtherFirstName: | BROCK | ||||||||
| OtherMiddleName: | ANTHONY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 440 MELVILL CRES | ||||||||
| Address2: | |||||||||
| City: | PHILOMATH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973709438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419086926 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1255 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416876983 | ||||||||
| FaxNumber: | 5417621571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2021 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.