Provider Demographics
NPI:1750636056
Name:DETRICK FAMILY CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:DETRICK FAMILY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-766-9600
Mailing Address - Street 1:601 GATES RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2288
Mailing Address - Country:US
Mailing Address - Phone:607-766-9600
Mailing Address - Fax:
Practice Address - Street 1:601 GATES RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2288
Practice Address - Country:US
Practice Address - Phone:607-766-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU80013Medicare UPIN