MEDICARE: MR. CHIP STEWART LYDICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1245662758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHIP STEWART LYDICK

Provider Business Mailing Address
First Line	:	8205 AYLESBURY AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7342
Country	:	US
Telephone Number	:	702-443-8632
Fax Number	:	702-586-7183

Provider Business Practice Location Address
First Line	:	8205 AYLESBURY AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7342
Country	:	US
Telephone Number	:	702-443-8632
Fax Number	:	702-586-7183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	08/07/2013

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