Provider Demographics
NPI:1376542993
Name:KIDDER ORTHOPEDIC LABORATORIES INC
Entity Type:Organization
Organization Name:KIDDER ORTHOPEDIC LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MESSER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, LPO
Authorized Official - Phone:352-795-5556
Mailing Address - Street 1:5676 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7555
Mailing Address - Country:US
Mailing Address - Phone:352-795-5556
Mailing Address - Fax:352-795-5218
Practice Address - Street 1:5676 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7555
Practice Address - Country:US
Practice Address - Phone:352-795-5556
Practice Address - Fax:352-795-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR20335E00000X
FLPOR193335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL950296300Medicaid
M2080OtherBCBS
FL950296300Medicaid