Provider Demographics
NPI:1639353014
Name:DETERS, RAYMOND LEROY III (DC)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LEROY
Last Name:DETERS
Suffix:III
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 1:2535 CAMINO DEL RIO S
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3754
Mailing Address - Country:US
Mailing Address - Phone:619-681-1919
Mailing Address - Fax:619-681-1922
Practice Address - Street 1:2535 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 225
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3754
Practice Address - Country:US
Practice Address - Phone:619-681-1919
Practice Address - Fax:619-681-1922
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20569Medicare PIN
CAU-70873Medicare UPIN