Provider Demographics
NPI:1932197092
Name:DETWILER, JULIE SUZANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:SUZANNE
Last Name:DETWILER
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 1:8231 MAIN ST
Mailing Address - Street 2:P.O. BOX 393
Mailing Address - City:KINSMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44428-9514
Mailing Address - Country:US
Mailing Address - Phone:330-876-1111
Mailing Address - Fax:330-876-1005
Practice Address - Street 1:8231 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:OH
Practice Address - Zip Code:44428-9514
Practice Address - Country:US
Practice Address - Phone:330-876-1111
Practice Address - Fax:330-876-1005
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2992111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2362250Medicaid
OH000000291058OtherANTHEM BCBS NPI
OH000000291058OtherUNICARE
OH450511098027OtherCARESOURCE
OH2362250Medicaid
P00031163Medicare PIN
OHU93279Medicare UPIN