Provider Demographics
NPI:1275722209
Name:FREDRICK FAMILY CHIROPRACTIC P C
Entity Type:Organization
Organization Name:FREDRICK FAMILY CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWSON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FREDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-233-9390
Mailing Address - Street 1:2601 1ST AVE N
Mailing Address - Street 2:SUITE B
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1304
Mailing Address - Country:US
Mailing Address - Phone:906-233-9390
Mailing Address - Fax:
Practice Address - Street 1:2601 1ST AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1304
Practice Address - Country:US
Practice Address - Phone:906-233-9390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008214111N00000X
MI2301009241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4247060Medicaid
MI950B110430OtherBLUE CROSS BLUE SHEILD
MI950B150130OtherBLUE CROSS BLUE SHEILD
MIU78466Medicare UPIN
MI950B110430OtherBLUE CROSS BLUE SHEILD