Provider Demographics
NPI:1861405516
Name:LYDON'S ORTHOTIC SERVICE
Entity type:Organization
Organization Name:LYDON'S ORTHOTIC SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LYDON
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:707-428-1705
Mailing Address - Street 1:1200 WESTERN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-2474
Mailing Address - Country:US
Mailing Address - Phone:707-428-1705
Mailing Address - Fax:707-428-1733
Practice Address - Street 1:1200 WESTERN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-2474
Practice Address - Country:US
Practice Address - Phone:707-428-1705
Practice Address - Fax:707-428-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1167222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0011670Medicaid
CAZZZ66766ZOtherBLUE SHIELD/BLUE CROSS
CAZZZ66766ZOtherBLUE SHIELD/BLUE CROSS