Provider Demographics
NPI:1972641744
Name:LANCE R FREDRICKSON DC PC
Entity type:Organization
Organization Name:LANCE R FREDRICKSON DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BARTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-271-8277
Mailing Address - Street 1:101 W 69TH STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2440
Mailing Address - Country:US
Mailing Address - Phone:605-271-8277
Mailing Address - Fax:605-271-7277
Practice Address - Street 1:101 W 69TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2440
Practice Address - Country:US
Practice Address - Phone:605-271-8277
Practice Address - Fax:605-271-7277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDU91353Medicare UPIN