Provider Demographics
NPI:1699840512
Name:DETRICK, DUSTIN J (DC, LCP)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:J
Last Name:DETRICK
Suffix:
Gender:M
Credentials:DC, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MIAMI STREET
Mailing Address - Street 2:
Mailing Address - City:FORT LORAMIE
Mailing Address - State:OH
Mailing Address - Zip Code:45845
Mailing Address - Country:US
Mailing Address - Phone:937-420-2500
Mailing Address - Fax:
Practice Address - Street 1:406 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT LORAMIE
Practice Address - State:OH
Practice Address - Zip Code:45845
Practice Address - Country:US
Practice Address - Phone:937-420-4000
Practice Address - Fax:937-420-4001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE9359631Medicare PIN
OHDE0829114Medicare PIN
OHU-66954Medicare UPIN