Healthcare Provider Details

I. General information

NPI: 1497956049
Provider Name (Legal Business Name): FREDERICK FAMILY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 W FOX RIDGE LN
MUNCIE IN
47304-5204
US

IV. Provider business mailing address

3415 W FOX RIDGE LN
MUNCIE IN
47304-5204
US

V. Phone/Fax

Practice location:
  • Phone: 765-286-9020
  • Fax: 765-286-9097
Mailing address:
  • Phone: 765-286-9020
  • Fax: 765-286-9097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002263A
License Number StateIN

VIII. Authorized Official

Name: DR. DONNA S FREDERICK
Title or Position: CHIROPRACTOR, OWNER
Credential: D.C.
Phone: 765-286-9020