Provider Demographics
NPI:1033725866
Name:LIDVALL, BRADLEY DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DOUGLAS
Last Name:LIDVALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28010 238TH ST
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9126
Mailing Address - Country:US
Mailing Address - Phone:480-200-2983
Mailing Address - Fax:
Practice Address - Street 1:2220 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2704
Practice Address - Country:US
Practice Address - Phone:480-200-2983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101934111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor