Provider Demographics
NPI:1801872999
Name:DETRICK, DOMONIQUE M (DC)
Entity type:Individual
Prefix:DR
First Name:DOMONIQUE
Middle Name:M
Last Name:DETRICK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E OTTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-2509
Mailing Address - Country:US
Mailing Address - Phone:724-838-7700
Mailing Address - Fax:724-838-7200
Practice Address - Street 1:125 E OTTERMAN ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2509
Practice Address - Country:US
Practice Address - Phone:724-838-7700
Practice Address - Fax:724-838-7200
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007066L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01664678Medicaid
PA924N9MMedicare ID - Type Unspecified
PA01664678Medicaid