Provider Demographics
NPI:1841464088
Name:DETRICK CHIROPRACTIC LLC
Entity type:Organization
Organization Name:DETRICK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LCP
Authorized Official - Phone:937-420-4000
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:406 SOUTH MAIN STREET
Mailing Address - City:FORT LORAMIE
Mailing Address - State:OH
Mailing Address - Zip Code:45845-0260
Mailing Address - Country:US
Mailing Address - Phone:937-420-4000
Mailing Address - Fax:937-420-4001
Practice Address - Street 1:406 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT LORAMIE
Practice Address - State:OH
Practice Address - Zip Code:45845-0260
Practice Address - Country:US
Practice Address - Phone:937-420-4000
Practice Address - Fax:937-420-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9359631Medicare PIN