Provider Demographics
NPI:1164923009
Name:DETTEN, DOUGLAS NEIL
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:NEIL
Last Name:DETTEN
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 1:9856 LA FRONTERA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1871
Mailing Address - Country:US
Mailing Address - Phone:806-344-0056
Mailing Address - Fax:
Practice Address - Street 1:8101 BOAT CLUB RD STE 318
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3633
Practice Address - Country:US
Practice Address - Phone:806-344-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion