Healthcare Provider Details

I. General information

NPI: 1083320030
Provider Name (Legal Business Name): CODY SHANE ALLISON BS, ACSM-CEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SW ABBEY ST
NEWPORT OR
97365-4820
US

IV. Provider business mailing address

3140 ELLIOT ST NW
SALEM OR
97304-1064
US

V. Phone/Fax

Practice location:
  • Phone: 541-574-4856
  • Fax: 541-768-9417
Mailing address:
  • Phone: 503-507-9124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number1066339
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: