Healthcare Provider Details

I. General information

NPI: 1356042386
Provider Name (Legal Business Name): CODY CONRAD MERRILL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S 10TH ST
OREGON IL
61061-2129
US

IV. Provider business mailing address

405 DEVONSHIRE ST
DIXON IL
61021-1116
US

V. Phone/Fax

Practice location:
  • Phone: 815-732-7994
  • Fax:
Mailing address:
  • Phone: 815-441-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160008092
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: