Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 010667 | GA |
N | 111NP0017X | Pediatric Chiropractor | 010667 | GA |
NPI | 1609534171 |
---|---|
Provider Name | Maggie Detrick |
First Address | Covington, GA 30014-6659 |
Second Address | Covington, GA 30014-6659 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2021 |
Last Update Date | 02/12/2021 |