Healthcare Provider Details

I. General information

NPI: 1174598593
Provider Name (Legal Business Name): CODY D. STEPHENS M.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N WHITLEY DR SUITE 1
FRUITLAND ID
83619-2705
US

IV. Provider business mailing address

215 N WHITLEY DR SUITE 1
FRUITLAND ID
83619-2705
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-6366
  • Fax: 208-452-6399
Mailing address:
  • Phone: 208-452-6366
  • Fax: 208-452-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberRPT1547
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: