Healthcare Provider Details

I. General information

NPI: 1366495202
Provider Name (Legal Business Name): FREDERICK WILLIAM STORER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MAGNOLIA WAY
TEQUESTA FL
33469
US

IV. Provider business mailing address

109 MAGNOLIA WAY
TEQUESTA FL
33469
US

V. Phone/Fax

Practice location:
  • Phone: 561-741-0079
  • Fax: 561-741-0079
Mailing address:
  • Phone: 561-741-0079
  • Fax: 561-741-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH003151
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMC01794
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX2107
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: