MEDICARE: DOUGLAS NEIL DETTEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372600000X	Adult Companion

General Provider Information

NPI Number	:	1164923009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS NEIL DETTEN

Provider Business Mailing Address
First Line	:	9856 LA FRONTERA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-1871
Country	:	US
Telephone Number	:	806-344-0056
Fax Number	:

Provider Business Practice Location Address
First Line	:	8101 BOAT CLUB RD STE 318
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3633
Country	:	US
Telephone Number	:	806-344-0056
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	02/26/2018

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Directions to “ DOUGLAS NEIL DETTEN ” Practice Location

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