1073618708 NPI number — DR. JENNIFER MARIE LIDSTROM M.S.,D.C.,P.C.

Table of content: DR. JENNIFER MARIE LIDSTROM M.S.,D.C.,P.C. (NPI 1073618708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073618708 NPI number — DR. JENNIFER MARIE LIDSTROM M.S.,D.C.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIDSTROM
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.S.,D.C.,P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073618708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19924 JETTON RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CORNELIUS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28031-8250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-876-8446
Provider Business Mailing Address Fax Number:
704-896-8495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19924 JETTON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-8250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-876-8446
Provider Business Practice Location Address Fax Number:
704-896-8495
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3249 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89085RN , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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