Provider Demographics
NPI:1780646596
Name:KIESECKER, FREDRICK (DC, CCN)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:
Last Name:KIESECKER
Suffix:
Gender:M
Credentials:DC, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 HYACINTH CT
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5627
Mailing Address - Country:US
Mailing Address - Phone:516-334-8425
Mailing Address - Fax:
Practice Address - Street 1:2520 HYACINTH CT
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5627
Practice Address - Country:US
Practice Address - Phone:516-334-8425
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006720111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30538Medicare UPIN
NYX55041Medicare ID - Type UnspecifiedMEDICARE