Healthcare Provider Details

I. General information

NPI: 1114735800
Provider Name (Legal Business Name): CODY MARSHALL APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28999 OLD TOWN FRONT ST STE 104
TEMECULA CA
92590-2842
US

IV. Provider business mailing address

28999 OLD TOWN FRONT ST STE 104
TEMECULA CA
92590-2842
US

V. Phone/Fax

Practice location:
  • Phone: 951-261-8392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPCC16009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: