Provider Demographics
NPI:1609266964
Name:FREDRICKS, ERIC (ATC, LAT, PES)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FREDRICKS
Suffix:
Gender:M
Credentials:ATC, LAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3172 PECAN LAKE DR
Mailing Address - Street 2:APARTMENT 205
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-0480
Mailing Address - Country:US
Mailing Address - Phone:616-826-8409
Mailing Address - Fax:
Practice Address - Street 1:1115 E GETWELL LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-4210
Practice Address - Country:US
Practice Address - Phone:901-678-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAT 00000018012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer