MEDICARE: KEVIN JOHN DIETRICH RN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	TX
2	251J00000X	Nursing Care Agency	TX
3	251B00000X	Case Management Agency	TX

General Provider Information

NPI Number	:	1801933320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN JOHN DIETRICH RN

Provider Business Mailing Address
First Line	:	4002 LOUETTA RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-4405
Country	:	US
Telephone Number	:	832-717-4083
Fax Number	:	832-422-2500

Provider Business Practice Location Address
First Line	:	4002 LOUETTA RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-4405
Country	:	US
Telephone Number	:	832-717-4083
Fax Number	:	281-655-5234

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	03/11/2024

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