Healthcare Provider Details

I. General information

NPI: 1578598645
Provider Name (Legal Business Name): CODY RYAN OKUDA M.S.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 GRAND MONTECITO PKWY SUITE 120
LAS VEGAS NV
89149-0260
US

IV. Provider business mailing address

3831 W CHARLESTON BLVD
LAS VEGAS NV
89102-1859
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-1540
  • Fax: 702-515-1578
Mailing address:
  • Phone: 702-876-1733
  • Fax: 702-878-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1803
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: