Provider Demographics
NPI:1366152332
Name:PHILLIP, DEMETRICE
Entity type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7016
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77522-7016
Mailing Address - Country:US
Mailing Address - Phone:281-865-8385
Mailing Address - Fax:
Practice Address - Street 1:827 MARIGOLD RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-7002
Practice Address - Country:US
Practice Address - Phone:281-865-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty