Provider Demographics
NPI:1922519883
Name:DEITRICK, KIRK LEWIS
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:LEWIS
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4938 OAK TREE CT
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-2549
Mailing Address - Country:US
Mailing Address - Phone:702-461-2591
Mailing Address - Fax:
Practice Address - Street 1:215 N STATE COLLEGE BLVD STE G
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2932
Practice Address - Country:US
Practice Address - Phone:714-999-6596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
CA48943225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant