Provider Demographics
NPI:1508972647
Name:DETRICK, ROBERT DANA (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DANA
Last Name:DETRICK
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 1:1461 SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS
Mailing Address - State:NY
Mailing Address - Zip Code:13812-2803
Mailing Address - Country:US
Mailing Address - Phone:814-558-0521
Mailing Address - Fax:
Practice Address - Street 1:601 GATES RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2288
Practice Address - Country:US
Practice Address - Phone:607-766-9600
Practice Address - Fax:607-766-9601
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009577-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80013Medicare UPIN
NYCC0230Medicare ID - Type Unspecified