Healthcare Provider Details

I. General information

NPI: 1457747990
Provider Name (Legal Business Name): LIDDY HEALTH & FITNESS CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6310 SAN VICENTE BLVD STE 240
LOS ANGELES CA
90048-5461
US

IV. Provider business mailing address

230 S JACKSON ST. #104
GLENDALE CA
91205
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-1959
  • Fax:
Mailing address:
  • Phone: 310-659-1959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC 31233
License Number StateCA

VIII. Authorized Official

Name: MR. KENNETH JEREMY YCMAT
Title or Position: PRESIDENT
Credential: D.C.
Phone: 310-659-1959