Healthcare Provider Details

I. General information

NPI: 1083178198
Provider Name (Legal Business Name): VICTOR ERUDE LIDAYWA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 02/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W JACKSON ST STE C
MACOMB IL
61455-3175
US

IV. Provider business mailing address

305 E SUMMIT ST
MACOMB IL
61455-3223
US

V. Phone/Fax

Practice location:
  • Phone: 309-331-3590
  • Fax:
Mailing address:
  • Phone: 309-837-1748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070.017800
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.017800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: