Healthcare Provider Details

I. General information

NPI: 1134823628
Provider Name (Legal Business Name): KRIS S DETGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 E HOPSON ST
BAD AXE MI
48413-1555
US

IV. Provider business mailing address

2084 E MAIN ST
UBLY MI
48475-9726
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-9983
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: