Provider Demographics
NPI:1134823628
Name:DETGEN, KRIS S
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:S
Last Name:DETGEN
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 1:2084 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UBLY
Mailing Address - State:MI
Mailing Address - Zip Code:48475-9726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1167 E HOPSON ST
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1555
Practice Address - Country:US
Practice Address - Phone:989-269-9983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant