=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366701203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN A. LIDDY, D.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2012
-----------------------------------------------------
Last Update Date | 05/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8920 W SUNSET BLVD STE 200
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-659-1959
-----------------------------------------------------
Fax | 310-659-4769
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8920 W SUNSET BLVD STE 200
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-659-1959
-----------------------------------------------------
Fax | 310-659-4769
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DEBORRA A LIDDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-659-1959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC16468
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | DC31888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | DC16468
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | DC31233
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------