Healthcare Provider Details

I. General information

NPI: 1467159160
Provider Name (Legal Business Name): LYDER ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W 24TH ST STE 12
NEW YORK NY
10011-1904
US

IV. Provider business mailing address

10 E 138TH ST APT 12D
NEW YORK NY
10037-2037
US

V. Phone/Fax

Practice location:
  • Phone: 917-209-5099
  • Fax:
Mailing address:
  • Phone: 917-209-5099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. BIANCA LYDER
Title or Position: CERTIFIED HAIR LOSS SPECIALIST
Credential: CEO
Phone: 917-209-5099