Provider Demographics
NPI:1013172543
Name:KIDDY, JOHN EDWARD JR (MS, ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:KIDDY
Suffix:JR
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 SAN CLARA DR APT A
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-5430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-297-2043
Practice Address - Fax:561-297-0468
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL2789246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
03070219OtherNATABOC CERTIFIED ATHLETIC TRAINER