Provider Demographics
NPI:1346601879
Name:DIETRICK, JAMES RYAN (DC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RYAN
Last Name:DIETRICK
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 1:14321 NORTHLAND DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2310
Mailing Address - Country:US
Mailing Address - Phone:616-916-6753
Mailing Address - Fax:
Practice Address - Street 1:14321 NORTHLAND DR
Practice Address - Street 2:STE 1
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2310
Practice Address - Country:US
Practice Address - Phone:231-629-8833
Practice Address - Fax:231-629-8834
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010554111N00000X, 111NS0005X
OR5702111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor