Provider Demographics
NPI:1598195950
Name:LYDECKER, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:LYDECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 WILLIAMS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2612
Mailing Address - Country:US
Mailing Address - Phone:805-981-4200
Mailing Address - Fax:805-981-3341
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-4200
Practice Address - Fax:805-981-3341
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA615429163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse