Provider Demographics
NPI:1336243971
Name:PETRUCCI, LIDO L (DC)
Entity Type:Individual
Prefix:DR
First Name:LIDO
Middle Name:L
Last Name:PETRUCCI
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 1:301 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-1240
Mailing Address - Country:US
Mailing Address - Phone:502-222-0000
Mailing Address - Fax:502-222-3488
Practice Address - Street 1:301 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-1240
Practice Address - Country:US
Practice Address - Phone:502-222-0000
Practice Address - Fax:502-222-3488
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2438072000OtherPASSPORT ADVANTAGE
KY9943660003OtherCIGNA
KY0974279OtherAETNA
KY000000051634OtherANTHEM
KY350048657OtherRAILROAD MEDICARE
KY1140365OtherPASSPORT
KY85036697Medicaid
KY85036697Medicaid
KY350048657OtherRAILROAD MEDICARE