Healthcare Provider Details

I. General information

NPI: 1467502906
Provider Name (Legal Business Name): FREDERICK ALLEN RICHARDSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 AVENIDA DEL MAR SUITE A
SAN CLEMENTE CA
92672-5540
US

IV. Provider business mailing address

3108 ESTAMPIDA
SAN CLEMENTE CA
92673-3223
US

V. Phone/Fax

Practice location:
  • Phone: 949-498-3262
  • Fax: 949-498-4718
Mailing address:
  • Phone: 949-573-1365
  • Fax: 949-498-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 15724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: