Healthcare Provider Details

I. General information

NPI: 1952829814
Provider Name (Legal Business Name): JOHN ADRIAN LIEDECKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 N SAN PEDRO RD STE 2021
SAN RAFAEL CA
94903-4158
US

IV. Provider business mailing address

101 BAYVIEW ST APT A
SAN RAFAEL CA
94901-4914
US

V. Phone/Fax

Practice location:
  • Phone: 936-661-2198
  • Fax:
Mailing address:
  • Phone: 936-661-2198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: