Provider Demographics
NPI:1720161276
Name:FRETTY, MARUICE KEITH (DC)
Entity type:Individual
Prefix:
First Name:MARUICE
Middle Name:KEITH
Last Name:FRETTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1613
Mailing Address - Country:US
Mailing Address - Phone:415-841-0115
Mailing Address - Fax:415-841-1710
Practice Address - Street 1:2549 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1613
Practice Address - Country:US
Practice Address - Phone:415-841-0115
Practice Address - Fax:415-841-1710
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25970111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0259700Medicare ID - Type Unspecified