Provider Demographics
NPI:1144529561
Name:LICKTEIG, BRET DEREK (DC)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:DEREK
Last Name:LICKTEIG
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 1:906 WALNUT ST
Mailing Address - Street 2:PO BOX 186
Mailing Address - City:VALLEY FALLS
Mailing Address - State:KS
Mailing Address - Zip Code:66088-1240
Mailing Address - Country:US
Mailing Address - Phone:785-945-3261
Mailing Address - Fax:785-945-3262
Practice Address - Street 1:906 WALNUT ST
Practice Address - Street 2:
Practice Address - City:VALLEY FALLS
Practice Address - State:KS
Practice Address - Zip Code:66088-1240
Practice Address - Country:US
Practice Address - Phone:785-945-3261
Practice Address - Fax:785-945-3262
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor