Healthcare Provider Details

I. General information

NPI: 1750411682
Provider Name (Legal Business Name): CHARLES JAMES FREDRICKS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5819 NW BARRY RD
KANSAS CITY MO
64154
US

IV. Provider business mailing address

7423 NW MOSER DR
WEATHERBY LAKE MO
64152-1792
US

V. Phone/Fax

Practice location:
  • Phone: 816-741-3855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2005026467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: