Provider Demographics
NPI:1790341899
Name:LYDOLPH, CHARLES ERNEST (L AC MAOM)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ERNEST
Last Name:LYDOLPH
Suffix:
Gender:M
Credentials:L AC MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6814 SEINFELD CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-2205
Mailing Address - Country:US
Mailing Address - Phone:713-628-2756
Mailing Address - Fax:
Practice Address - Street 1:22450 TOMBALL PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1529
Practice Address - Country:US
Practice Address - Phone:832-706-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01915171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist