Provider Demographics
NPI:1598760258
Name:PHILLIPS, FREDERICK B JR (DC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:B
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:B
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4010 NW CACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3634
Mailing Address - Country:US
Mailing Address - Phone:580-357-8688
Mailing Address - Fax:580-357-7483
Practice Address - Street 1:4010 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3634
Practice Address - Country:US
Practice Address - Phone:580-357-8688
Practice Address - Fax:580-357-7483
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1907111NN0400X, 133NN1002X, 111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5346Medicare PIN
OKOK700400Medicare PIN