Provider Demographics
NPI:1598164147
Name:LIDDY, CHRISTOPHER MARTIN (RD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MARTIN
Last Name:LIDDY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-0308
Mailing Address - Country:US
Mailing Address - Phone:662-252-2285
Mailing Address - Fax:662-252-2394
Practice Address - Street 1:575 CRAFT ST
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3249
Practice Address - Country:US
Practice Address - Phone:662-252-2285
Practice Address - Fax:662-252-2394
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered