Provider Demographics
NPI:1922008127
Name:LIDELL, LYNN RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:RUSSELL
Last Name:LIDELL
Suffix:
Gender:M
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:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-0503
Mailing Address - Country:US
Mailing Address - Phone:512-639-8324
Mailing Address - Fax:512-868-5977
Practice Address - Street 1:2913 WILLIAMS DR
Practice Address - Street 2:STE 210
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2739
Practice Address - Country:US
Practice Address - Phone:512-639-8324
Practice Address - Fax:512-868-5977
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609169Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TXU72689Medicare UPIN