Healthcare Provider Details

I. General information

NPI: 1043492549
Provider Name (Legal Business Name): DR. JOHN LIDDY, DC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 WESTMOUNT DR
WEST HOLLYWOOD CA
90069-5108
US

IV. Provider business mailing address

8581 SANTA MONICA BLVD # 406
WEST HOLLYWOOD CA
90069-4120
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-1959
  • Fax: 310-659-4769
Mailing address:
  • Phone: 310-659-1959
  • Fax: 310-659-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC16468
License Number StateCA

VIII. Authorized Official

Name: MS. FELICIA THOMAS
Title or Position: OWNER BILLING SERVICE
Credential:
Phone: 858-504-0595