Healthcare Provider Details

I. General information

NPI: 1609266964
Provider Name (Legal Business Name): ERIC FREDRICKS ATC, LAT, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E GETWELL LOOP
MEMPHIS TN
38152-4210
US

IV. Provider business mailing address

3172 PECAN LAKE DR APARTMENT 205
MEMPHIS TN
38115-0480
US

V. Phone/Fax

Practice location:
  • Phone: 901-678-3536
  • Fax:
Mailing address:
  • Phone: 616-826-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 0000001801
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: