Provider Demographics
NPI:1457747990
Name:LIDDY HEALTH & FITNESS CHIROPRACTIC INC
Entity Type:Organization
Organization Name:LIDDY HEALTH & FITNESS CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JEREMY
Authorized Official - Last Name:YCMAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-659-1959
Mailing Address - Street 1:230 S JACKSON ST. #104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:310-659-1959
Mailing Address - Fax:
Practice Address - Street 1:6310 SAN VICENTE BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5461
Practice Address - Country:US
Practice Address - Phone:310-659-1959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-11
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 31233111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty