Healthcare Provider Details

I. General information

NPI: 1053897272
Provider Name (Legal Business Name): CODY SOOHOO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13223 VENTURA BLVD
STUDIO CITY CA
91604-1801
US

IV. Provider business mailing address

808 WESTMORELAND DR
MONTEBELLO CA
90640-2452
US

V. Phone/Fax

Practice location:
  • Phone: 818-981-2639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: