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General NPI Number Information
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NPI Number | 1093797052
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Entity Type | Individual
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Provider Name | KENNETH CHARLES DETRING O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/16/2005
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Last Update Date | 02/28/2008
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Provider Practice Location Address
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Address Line | 1014 E JACKSON BLVD
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City | JACKSON
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State | MO
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Zip | 63755-2436
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Country | US
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Telephone | 573-243-2020
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Fax | 573-243-6684
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Provider Business Mailing Address
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Address Line | PO BOX 510
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City | JACKSON
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State | MO
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Zip | 63755-0510
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Country | US
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Telephone | 573-243-2020
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Fax | 573-243-6684
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TO2426
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License Number State | MO
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