Provider Demographics
NPI:1639171705
Name:DETTE, KEVIN WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:DETTE
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 1:123 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-6007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6007
Practice Address - Country:US
Practice Address - Phone:760-643-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 27980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU94154Medicare UPIN