Provider Demographics
NPI:1700493483
Name:KIDD, BLAINE MICHAEL
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:MICHAEL
Last Name:KIDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3426 WAVERLY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-7320
Mailing Address - Country:US
Mailing Address - Phone:765-414-9245
Mailing Address - Fax:
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:800-497-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program