Provider Demographics
NPI:1902026248
Name:FREDRICKSON CHIROPRACTIC CLINIC PS
Entity Type:Organization
Organization Name:FREDRICKSON CHIROPRACTIC CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-738-2069
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-0788
Mailing Address - Country:US
Mailing Address - Phone:509-738-2386
Mailing Address - Fax:509-738-2386
Practice Address - Street 1:355 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141
Practice Address - Country:US
Practice Address - Phone:509-738-2386
Practice Address - Fax:509-738-2386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2094902Medicaid
WAT02297Medicare UPIN
WA2094902Medicaid