Individual
NICKLAS LIDSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
925 ONE LANDON LOOP, CONWAY, SC 29528
(843) 349-2825
Mailing address
111 VILLAGE CENTER BLVD UNIT 2210, MYRTLE BEACH, SC 29579-6719
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT03472
SC
Other
Enumeration date
12/04/2023
Last updated
12/04/2023
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