Healthcare Provider Details

I. General information

NPI: 1104555630
Provider Name (Legal Business Name): CODY MUNDAY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W FRANCIS ST.
ONTARIO CA
91762
US

IV. Provider business mailing address

PO BOX 1113
WRIGHTWOOD CA
92397-1113
US

V. Phone/Fax

Practice location:
  • Phone: 909-988-7411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2000026040
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2000026040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: