Healthcare Provider Details

I. General information

NPI: 1366701203
Provider Name (Legal Business Name): JOHN A. LIDDY, D.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2012
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8920 W SUNSET BLVD STE 200
WEST HOLLYWOOD CA
90069-1812
US

IV. Provider business mailing address

8920 W SUNSET BLVD STE 200
WEST HOLLYWOOD CA
90069-1812
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 TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC16468
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC31888
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC16468
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC31233
License Number StateCA

VIII. Authorized Official

Name: DEBORRA A LIDDY
Title or Position: OFFICE MANAGER
Credential:
Phone: 310-659-1959