Provider Demographics
NPI:1063673572
Name:FREDERICKS CHIROPRACTIC CENTER, LTD.
Entity Type:Organization
Organization Name:FREDERICKS CHIROPRACTIC CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREDERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-665-5656
Mailing Address - Street 1:166 N GARY AVE
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2093
Mailing Address - Country:US
Mailing Address - Phone:630-665-5656
Mailing Address - Fax:
Practice Address - Street 1:166 N GARY AVE
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2093
Practice Address - Country:US
Practice Address - Phone:630-665-5656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL764930OtherMEDICARE
ILT38747OtherUPIN
IL2215441OtherBLUE CROSS BLUE SHIELD OF ILLINOIS