Healthcare Provider Details

I. General information

NPI: 1639759467
Provider Name (Legal Business Name): CODY LYFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CHIPMAN WAY
KINGSTON MA
02364-1039
US

IV. Provider business mailing address

PO BOX 1424
PRESQUE ISLE ME
04769-1424
US

V. Phone/Fax

Practice location:
  • Phone: 781-585-4100
  • Fax:
Mailing address:
  • Phone: 207-227-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: