Provider Demographics
NPI:1366565814
Name:DETTLOFF, JOHN C (BS, DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:DETTLOFF
Suffix:
Gender:M
Credentials:BS, DC
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 5424
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77325-5424
Mailing Address - Country:US
Mailing Address - Phone:281-298-7006
Mailing Address - Fax:
Practice Address - Street 1:330 RAYFORD RD
Practice Address - Street 2:STE 129
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-1980
Practice Address - Country:US
Practice Address - Phone:281-298-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4726111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603276Medicare ID - Type Unspecified