Provider Demographics
NPI:1619098621
Name:FREDERICK, BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:FREDERICK
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 1:3283 MOTOR AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3709
Mailing Address - Country:US
Mailing Address - Phone:310-559-6900
Mailing Address - Fax:310-836-8664
Practice Address - Street 1:3283 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3709
Practice Address - Country:US
Practice Address - Phone:310-559-6900
Practice Address - Fax:310-836-8664
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15926111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC15926AMedicare ID - Type Unspecified
CAT05957Medicare UPIN