Provider Demographics
NPI:1790777944
Name:DEVER, LYDIA L (DC)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:L
Last Name:DEVER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 JILES ROAD
Mailing Address - Street 2:BLDG 100 SUITE 101
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:678-290-3263
Mailing Address - Fax:678-290-2859
Practice Address - Street 1:3903 JILES ROAD
Practice Address - Street 2:BLDG 100 SUITE 101
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7147
Practice Address - Country:US
Practice Address - Phone:678-290-3263
Practice Address - Fax:678-290-2859
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:2006-04-10
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
GACHIR007392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU94413Medicare UPIN
GA35ZCHFCMedicare ID - Type Unspecified