Provider Demographics
NPI:1700137676
Name:FREDRICK, WILLIAM ALAN (LPO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALAN
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2128
Mailing Address - Country:US
Mailing Address - Phone:321-638-0262
Mailing Address - Fax:321-638-4559
Practice Address - Street 1:966 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2128
Practice Address - Country:US
Practice Address - Phone:321-638-0262
Practice Address - Fax:321-638-4559
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR851744P3200X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist