Healthcare Provider Details

I. General information

NPI: 1114144300
Provider Name (Legal Business Name): DRS. DETRICK & DETRICK INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 MONCLOVA ROAD SUITE 14
MAUMEE OH
43537
US

IV. Provider business mailing address

5757 MONCLOVA ROAD SUITE 14
MAUMEE OH
43537
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-3316
  • Fax:
Mailing address:
  • Phone: 419-893-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN113039
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number032039822
License Number StateOH

VIII. Authorized Official

Name: CYNDEE J DETRICK
Title or Position: OFFICE MANAGER
Credential:
Phone: 419-893-3316