Provider Demographics
NPI:1467502906
Name:RICHARDSON, FREDERICK ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ALLEN
Last Name:RICHARDSON
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 1:3108 ESTAMPIDA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3223
Mailing Address - Country:US
Mailing Address - Phone:949-573-1365
Mailing Address - Fax:949-498-4718
Practice Address - Street 1:214 AVENIDA DEL MAR
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5540
Practice Address - Country:US
Practice Address - Phone:949-498-3262
Practice Address - Fax:949-498-4718
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 15724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC15724OtherCHIROPRACTIC LICENSE
CAZZZ57891YOtherBLUE SHIELD
CABZ717AMedicare PIN