Provider Demographics
NPI:1366701203
Name:JOHN A. LIDDY, D.C.
Entity type:Organization
Organization Name:JOHN A. LIDDY, D.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-659-1959
Mailing Address - Street 1:8920 W SUNSET BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-1812
Mailing Address - Country:US
Mailing Address - Phone:310-659-1959
Mailing Address - Fax:310-659-4769
Practice Address - Street 1:8920 W SUNSET BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-1812
Practice Address - Country:US
Practice Address - Phone:310-659-1959
Practice Address - Fax:310-659-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-13
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16468111N00000X, 111NS0005X
CADC31888111NR0400X
CADC31233111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty