Provider Demographics
NPI:1043279656
Name:FREDRICH, MARK S (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:FREDRICH
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 1:20015 HWY 99
Mailing Address - Street 2:STE A
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036
Mailing Address - Country:US
Mailing Address - Phone:425-771-2225
Mailing Address - Fax:425-670-8121
Practice Address - Street 1:20015 HWY 99
Practice Address - Street 2:STE A
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036
Practice Address - Country:US
Practice Address - Phone:425-771-2225
Practice Address - Fax:425-670-8121
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002873111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4446921Medicare UPIN
GAB20580Medicare ID - Type Unspecified