Provider Demographics
NPI:1306883566
Name:DETERMAN, KEVIN JOHN (BS,DC,FASA)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:DETERMAN
Suffix:
Gender:M
Credentials:BS,DC,FASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9680
Mailing Address - Country:US
Mailing Address - Phone:904-900-1477
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-900-1477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7602903Medicaid
SDS4742Medicare ID - Type UnspecifiedNON-PROVIDER