Organization
LYDON'S ORTHOTIC SERVICE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. EDWARD JOSEPH LYDON C.O. (OWNER)
(707) 428-1705
Entity
Organization
Contact information
Practice address
1200 WESTERN STREET, SUITE B, FAIRFIELD, CA 94533-2474
(707) 428-1705
(707) 428-1733
Mailing address
1200 WESTERN STREET, SUITE B, FAIRFIELD, CA 94533-2474
(707) 428-1705
(707) 428-1733
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
Primary
CO1167
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
XA0011670
—
CA
01
—
ZZZ66766Z
BLUE SHIELD/BLUE CROSS
CA
Enumeration date
08/14/2006
Last updated
08/22/2020
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