=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376542993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDDER ORTHOPEDIC LABORATORIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2005
-----------------------------------------------------
Last Update Date | 12/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5676 W GULF TO LAKE HWY
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-5556
-----------------------------------------------------
Fax | 352-795-5218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5676 W GULF TO LAKE HWY
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-5556
-----------------------------------------------------
Fax | 352-795-5218
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN E MESSER
-----------------------------------------------------
Credential | CPO, LPO
-----------------------------------------------------
Telephone | 352-795-5556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | POR20
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | POR193
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------