Healthcare Provider Details

I. General information

NPI: 1356288732
Provider Name (Legal Business Name): CODY SIMONSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 S FITNESS PL STE 150
EAGLE ID
83616-7035
US

IV. Provider business mailing address

1691 N EAGLE RD
EAGLE ID
83616-3843
US

V. Phone/Fax

Practice location:
  • Phone: 208-507-8119
  • Fax:
Mailing address:
  • Phone: 208-507-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9071669
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: