Provider Demographics
NPI:1902455165
Name:MUNDY, LYDIA M (DC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:MUNDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4195 MANNHEIM RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9625
Mailing Address - Country:US
Mailing Address - Phone:812-634-6000
Mailing Address - Fax:812-634-7001
Practice Address - Street 1:4195 MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9625
Practice Address - Country:US
Practice Address - Phone:812-634-6000
Practice Address - Fax:812-634-7001
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003115A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor