Provider Demographics
NPI:1871369603
Name:LIDSTROM, NICKLAS
Entity type:Individual
Prefix:
First Name:NICKLAS
Middle Name:
Last Name:LIDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 VILLAGE CENTER BLVD UNIT 2210
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:925 ONE LANDON LOOP
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29528
Practice Address - Country:US
Practice Address - Phone:843-349-2825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAT034722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer