Provider Demographics
NPI:1437253903
Name:FREDRICKSON, LANCE (DC)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:FREDRICKSON
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 1:101 W 69TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2408
Mailing Address - Country:US
Mailing Address - Phone:605-271-8277
Mailing Address - Fax:605-271-7277
Practice Address - Street 1:101 W 69TH ST
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2408
Practice Address - Country:US
Practice Address - Phone:605-271-8277
Practice Address - Fax:605-271-7277
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDU91353Medicare UPIN