Provider Demographics
NPI:1588803001
Name:LYDICK, WILLIAM SHANNON (LAC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SHANNON
Last Name:LYDICK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37466 BANKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7825
Mailing Address - Country:US
Mailing Address - Phone:760-328-2232
Mailing Address - Fax:
Practice Address - Street 1:35325 DATE PALM DR
Practice Address - Street 2:STE. 107
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7014
Practice Address - Country:US
Practice Address - Phone:760-328-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3638171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist