Provider Demographics
NPI:1710102165
Name:DETRINIS, VINCENT PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:PAUL
Last Name:DETRINIS
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 1:3 SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1817
Mailing Address - Country:US
Mailing Address - Phone:631-689-2993
Mailing Address - Fax:
Practice Address - Street 1:3 SAGE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1817
Practice Address - Country:US
Practice Address - Phone:631-689-2993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX4504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX25681Medicare PIN