Provider Demographics
NPI:1609534171
Name:DETRICK, MAGGIE (DC)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:DETRICK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 PACE ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-6659
Mailing Address - Country:US
Mailing Address - Phone:770-786-2818
Mailing Address - Fax:844-760-0502
Practice Address - Street 1:2125 PACE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-6659
Practice Address - Country:US
Practice Address - Phone:770-786-2818
Practice Address - Fax:844-760-0502
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010667111NP0017X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty