Healthcare Provider Details

I. General information

NPI: 1902529001
Provider Name (Legal Business Name): CODY HURST RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15351 W BELL RD
SURPRISE AZ
85374-4580
US

IV. Provider business mailing address

8528 W MIDWAY AVE
GLENDALE AZ
85305-6702
US

V. Phone/Fax

Practice location:
  • Phone: 877-809-5092
  • Fax:
Mailing address:
  • Phone: 623-230-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86114776
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: