Provider Demographics
NPI:1093279622
Name:EARTHLY, DEMETRIUS DONTE
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:DONTE
Last Name:EARTHLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9494
Mailing Address - Country:US
Mailing Address - Phone:707-624-2717
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9494
Practice Address - Country:US
Practice Address - Phone:707-624-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31763227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered