Provider Demographics
NPI:1043492549
Name:DR. JOHN LIDDY, DC
Entity type:Organization
Organization Name:DR. JOHN LIDDY, DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER BILLING SERVICE
Authorized Official - Prefix:MS
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-504-0595
Mailing Address - Street 1:8581 SANTA MONICA BLVD # 406
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4120
Mailing Address - Country:US
Mailing Address - Phone:310-659-1959
Mailing Address - Fax:310-659-4769
Practice Address - Street 1:606 WESTMOUNT DR
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-5108
Practice Address - Country:US
Practice Address - Phone:310-659-1959
Practice Address - Fax:310-659-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16468OtherSTATE LICENSE
CAT18342Medicare UPIN