Provider Demographics
NPI:1679048482
Name:IBACH, JAMES JOSEPH DETWILER (LPTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:JOSEPH DETWILER
Last Name:IBACH
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-2329
Mailing Address - Country:US
Mailing Address - Phone:302-258-9676
Mailing Address - Fax:
Practice Address - Street 1:907 N DUPONT BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1060
Practice Address - Country:US
Practice Address - Phone:302-422-2518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0001279225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEXHD127830688001Medicaid