Provider Demographics
NPI:1467891762
Name:LYDIAN CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LYDIAN CHIROPRACTIC LLC
Other - Org Name:LYDIAN CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-876-9099
Mailing Address - Street 1:777 CONCORD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1056
Mailing Address - Country:US
Mailing Address - Phone:617-876-9099
Mailing Address - Fax:617-876-9011
Practice Address - Street 1:777 CONCORD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1056
Practice Address - Country:US
Practice Address - Phone:617-876-9099
Practice Address - Fax:617-876-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty