Provider Demographics
NPI:1770592800
Name:LIDDLE, LARRY JEROME (DC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:JEROME
Last Name:LIDDLE
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 1:103 E CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132
Mailing Address - Country:US
Mailing Address - Phone:386-423-7575
Mailing Address - Fax:386-423-7575
Practice Address - Street 1:103 EAST CONNECTICUT
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132
Practice Address - Country:US
Practice Address - Phone:386-423-7575
Practice Address - Fax:386-423-7575
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor